Lower peak VO(2)implies poorer prognosis across a range of values from 10 to 20 ml. kg(-1)min(-1), without a unique threshold. Gradations of elevation of the VE/VCO(2)slope also carry prognostic information over a wide range (30-55). The two parameters are comparable in terms of prognostic power, and contribute complementary prognostic information.

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Background-Serum uric acid (UA) could be a valid prognostic marker and useful for metabolic, hemodynamic, and functional (MFH) staging in chronic heart failure (CHF). Methods and Results-For the derivation study, 112 patients with CHF (age 59Ϯ12 years, peak oxygen consumption [V O 2 ] 17Ϯ7 mL/kg per minute) were recruited. In separate studies, we validated the prognostic value of UA (nϭ182) and investigated the relationship between MFH score and the decision to list patients for heart transplantation (nϭ120). In the derivation study, the best mortality predicting UA cutoff (at 12 months) was 565 mol/L (9.50 mg/dL) (independently of age, peak V O 2 , left ventricular ejection fraction, diuretic dose, sodium, creatinine, and urea; PϽ0.0001). In the validation study, UA Ն565 mol/L predicted mortality (hazard ratio, 7.14; PϽ0.0001). In 16 patients (from both studies) with UA Ն565 mol/L, left ventricular ejection fraction Յ25% and peak V O 2 Յ14 mL/kg per min (MFH score 3), 12-month survival was lowest (31%) compared with patients with 2 (64%), 1 (77%), or no (98%, PϽ0.0001) risk factor. In an independent study, 51% of patients with MFH score 2 and 81% of patients with MFH score 3 were listed for transplantation. The positive predictive value of not being listed for heart transplantation with an MFH score of 0 or 1 was 100%. Conclusions-High serum UA levels are a strong, independent marker of impaired prognosis in patients with moderate to severe CHF. The relationship between serum UA and survival in CHF is graded. MFH staging of patients with CHF is feasible.

Aims: To investigate the hypothesis that changes in the ECG over time may be an important and readily available marker of prognostic value in patients with heart failure. Methods: 112 elderly patients (81 men) with stable heart failure, a mean (SD) age of 73.3 (4.4) years, left ventricular ejection fraction 38 (17)%, and peak oxygen consumption 15.1 (4.7) ml/kg/min had ECG measurements on two occasions a minimum of 12 (5) months apart. Results: During the subsequent follow up period (mean 27 (17) months) 45 patients died. QRS duration (p = 0.001) and heart rate (p = 0.03) at baseline were found by Cox proportional hazard method analysis to predict adverse outcomes in these patients. Of the changes in ECG parameters between the first and second visit, broadening of QRS duration (p = 0.001) predicted mortality. On Kaplan-Meier survival analysis, patients with < 5% change in QRS duration had fewer end points than patients with 5-20% change. A > 20% increase in QRS duration was associated with the worst prognosis. Progressive prolongation of QRS duration correlated closely with deterioration of LV systolic and diastolic function. Conclusion: A single measurement of QRS duration has significant prognostic value in elderly patients with heart failure and the increase in QRS duration over time is an even better predictor of adverse out comes.

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SUMMARY.Animal studies show signi®cant differences in steroid metabolism between male and female subjects. Similar studies in human subjects are still needed. The aim of this study was to evaluate differences in 24-h urinary excretion of cortisol and androgen metabolites between healthy male and female volunteers to estimate if such differences were signi®cant. Urinary metabolite measurements were performed by gas chromatography. The median urinary excretion of total cortisol metabolites was 6965 g/day for men and 4595 g/day for women (P=0´0005). Urinary excretion of 11 -hydroxyandrosterone, tetrahydrocortisone, tetrahydrocortisol (5 ), allotetrahydrocortisol (5 ), -cortolone, -cortolone+ -cortol and -cortol were also signi®cantly different in men compared with women. Total androgen metabolites in men (2660 g/day) were also higher than in women (1850 g/day) (P5 0´0003). Similarly, urinary excretion of androsterone (5 ), aetiocholanolone (5 ) and dehydroepiandrosterone were also signi®cantly greater (all P=0´01). This con®rms signi®cant differences in the steroid metabolite excretion pro®les between men and women. Laboratories should consider adopting gender-related reference ranges for cortisol and androgen metabolite excretion in 24-h urine samples.

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