EART FAILURE ACCOUNTS DIrectly for 55 000 deaths and indirectly for an additional 230 000 deaths in the United States each year. 1 Despite advances in care, the prognosis for patients with symptomatic heart failure remains poor, with median life expectancy of less than 5 years. 2 For those with the most advanced disease, 1-year mortality rates approach 90%. 3,4 About half of these deaths are due to progressive pump failure, while the remainder are sudden. 5 Prognosis is highly dependent on a multitude of patient characteristics, and a number of prognostic models have been developed to help predict survival in patients with heart failure. 6-9 Given the progressive nature of heart failure, its high mortality rate, and its predilection for affecting elderly persons, end-of-life issues should be at the forefront of heart failure management. In recognition of this, practice guidelines from major cardiovascular societies include sections on end-oflife considerations, which advocate ongoing patient and family education regarding prognosis for quality of life and survival. 10-12 Despite these guidelines, data on end-of-life issues in heart fail-For editorial comment see p 2566.

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OBJECTIVE To assess the impact of changes in symptoms of depression over a 1-year time period on subsequent clinical outcomes in heart failure (HF) patients. BACKGROUND Emerging evidence shows that clinical depression, which is prevalent among patients with HF, is associated with a poor prognosis. However, it is uncertain how changes in depression symptoms over time may relate to clinical outcomes. METHODS 147 HF outpatients, with ejection fraction (EF) <40%, were assessed for depressive symptoms using the Beck Depression Inventory (BDI) at baseline and again one year later. Cox Proportional Hazards regression analyses, controlling for established risk factors, were used to evaluate how changes in depressive symptoms were related to a combined primary endpoint of death or cardiovascular hospitalization over a median follow-up period of 5 years (with range of 4 to 7 years and no losses to follow-up). RESULTS 1-year change in symptoms of depression, as indicated by higher BDI scores over a 1-year interval (BDI change (1-point) Hazard Ratio=1.07; 95% CI 1.02-1.12; p=.007), were associated with death or cardiovascular hospitalization after controlling for baseline depression (baseline BDI Hazard Ratio = 1.1; 95% CI 1.06-1.14, p<.001) and established risk factors, including HF etiology, age, EF, NT-proBNP, and prior hospitalizations. CONCLUSIONS Worsening symptoms of depression are associated with a poorer prognosis in HF patients. Routine assessment of symptoms of depression in HF patients may help guide appropriate medical management of these patients who are at increased risk for adverse clinical outcomes.

To further investigate the Renner−Teller effect and barriers to linearity and dissociation in the simplest singlet carbene (HCF), we recorded fluorescence excitation spectra of the pure bending transitions with n = 0−7 and the combination bands   with n = 1−6 and   with n = 0−3 in the HCF Ã1A‘ ‘ ← X̃1A‘ system. The spectra were measured under jet-cooled conditions, using a pulsed-discharge source, and rotationally analyzed to yield precise values for the band origins and rotational constants. The derived Ã-state parameters are in excellent agreement with the predictions of ab initio electronic structure theory. The approach to linearity in the à state is evidenced in a sharp increase in the rotational constant A, as first reported by Kable and co-workers, and a minimum in the vibrational intervals near the 27 level. A fit of the vibrational intervals for the pure bending levels yields a barrier to linearity of 6300 ± 270 cm-1 above the vibrationless level. Our observation of the K a‘ = 1 level of 1126 places a lower limit on the à state barrier to dissociation of ∼ 8555 cm-1 above the vibrationless level.