1
|
Tersalvi G, Bossard M, Aeschbacher S, Wiencierz A, Beer JH, Rodondi N, Gencer BF, Reichlin T, Auricchio A, Ammann P, Moschovitis G, Bonati L, Osswald S, Kühne M, Conen D, Kobza R. Prevalence and outcomes of heart failure phenotypes in patients with atrial fibrillation. Int J Cardiol 2024; 412:132320. [PMID: 38964549 DOI: 10.1016/j.ijcard.2024.132320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/06/2024] [Accepted: 07/01/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is common in patients with heart failure (HF). Real-world data about long-term outcomes and rhythm control interventions use in AF patients with and without HF remain scarce. METHODS AF patients from two prospective, multicentre studies were classified based on the HF status at baseline into: HF with preserved ejection fraction (HFpEF), HF with reduced or mildly reduced ejection fraction (HFrEF/HFmrEF), and no HF. The prespecified primary outcome was risk of HF hospitalisation. Other outcomes of interest included mortality, cardiovascular events, AF progression, and quality of life. RESULTS A total of 1265 patients with AF were analysed (mean age 69.6 years, women 27.4%) with a median follow-up of 5.98 years. Patients with HFpEF (n = 126) had a 2.69-fold and patients with HFrEF/HFmrEF (n = 308) had a 2.12-fold increased risk of HF hospitalisation compared to patients without HF (n = 831, p < 0.001). Similar results applied for all-cause and cardiovascular mortality. The risk for AF progression was higher for patients with HFpEF and HFrEF/HFmrEF (6.30 and 6.79 per 100 patient-years, respectively) compared to patients without HF (4.20). The use of rhythm control strategies during follow-up was least in the HFpEF population (4.56 per 100 patient-years) compared to 7.74 in HFrEF/HFmrEF and 8.03 in patients with no HF. With regards to quality of life over time, this was worst among HFpEF patients. CONCLUSIONS The presence of HFpEF among patients with AF carried a high risk of HF hospitalisations and AF progression, and worse quality of life. Rhythm control interventions were rarely offered to HFpEF patients. These results uncover an unmet need for enhanced therapeutic interventions in patients with AF and HFpEF.
Collapse
Affiliation(s)
- Gregorio Tersalvi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland; Department of Internal Medicine, Ente Ospedaliero Cantonale (EOC), Mendrisio, Switzerland.
| | - Matthias Bossard
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland; Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Stefanie Aeschbacher
- Department of Cardiology, University of Basel Hospital, Basel, Switzerland.; Cardiovascular Research Institute, University of Basel Hospital, Basel, Switzerland
| | - Andrea Wiencierz
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Jürg H Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, Baden, Switzerland; Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Baris F Gencer
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland; Department of Cardiology, University Hospital of Geneva, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Angelo Auricchio
- Department of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Peter Ammann
- Department of Cardiology, Kantonsspital St Gallen, St. Gallen, Switzerland
| | - Giorgio Moschovitis
- Division of Cardiology, Ente Ospedaliero Cantonale (EOC), Cardiocentro Ticino Institute, Regional Hospital of Lugano, Lugano, Switzerland
| | - Leo Bonati
- Department of Neurology, University of Basel Hospital, Basel, Switzerland; Department of Research, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Stefan Osswald
- Department of Cardiology, University of Basel Hospital, Basel, Switzerland.; Cardiovascular Research Institute, University of Basel Hospital, Basel, Switzerland
| | - Michael Kühne
- Department of Cardiology, University of Basel Hospital, Basel, Switzerland.; Cardiovascular Research Institute, University of Basel Hospital, Basel, Switzerland
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Richard Kobza
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| |
Collapse
|
2
|
Liu H, Magaye R, Kaye DM, Wang BH. Heart Failure with Preserved Ejection Fraction: The Role of Inflammation. Eur J Pharmacol 2024:176858. [PMID: 39074526 DOI: 10.1016/j.ejphar.2024.176858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 07/15/2024] [Accepted: 07/24/2024] [Indexed: 07/31/2024]
Abstract
Heart failure (HF) is a debilitating clinical syndrome affecting 64.3 million patients worldwide. More than 50% of HF cases are attributed to HF with preserved ejection fraction (HFpEF), an entity growing in prevalence and mortality. Although recent breakthroughs reveal the prognostic benefits of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in HFpEF, there is still a lack of effective pharmacological therapy available. This highlights a major gap in medical knowledge that must be addressed. Current evidence attributes HFpEF pathogenesis to an interplay between cardiometabolic comorbidities, inflammation, and renin-angiotensin-aldosterone-system (RAAS) activation, leading to cardiac remodelling and diastolic dysfunction. However, conventional RAAS blockade has demonstrated limited benefits in HFpEF, which emphasises that alternative therapeutic targets should be explored. Presently, there is limited literature examining the use of anti-inflammatory HFpEF therapies despite growing evidence supporting its importance in disease progression. Hence, this review aims to explore current perspectives on HFpEF pathogenesis, including the importance of inflammation-driven cardiac remodelling and the therapeutic potential of anti-inflammatory therapies.
Collapse
Affiliation(s)
- Hongyi Liu
- Monash Alfred Baker Centre for Cardiovascular Research, School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC 3004 Australia; Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia; Biomarker Discovery Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia.
| | - Ruth Magaye
- Monash Alfred Baker Centre for Cardiovascular Research, School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC 3004 Australia; Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia.
| | - David M Kaye
- Monash Alfred Baker Centre for Cardiovascular Research, School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC 3004 Australia; Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia.
| | - Bing H Wang
- Monash Alfred Baker Centre for Cardiovascular Research, School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC 3004 Australia; Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia; Biomarker Discovery Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia.
| |
Collapse
|
3
|
Oraii A, McIntyre WF, Parkash R, Kowalik K, Razeghi G, Benz AP, Belley-Côté EP, Conen D, Connolly SJ, Tang ASL, Healey JS, Wong JA. Atrial Fibrillation Ablation in Heart Failure With Reduced vs Preserved Ejection Fraction: A Systematic Review and Meta-Analysis. JAMA Cardiol 2024; 9:545-555. [PMID: 38656292 PMCID: PMC11044015 DOI: 10.1001/jamacardio.2024.0675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/19/2024] [Indexed: 04/26/2024]
Abstract
Importance Catheter ablation is associated with reduced heart failure (HF) hospitalization and death in select patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF). However, the benefit in patients with HF with preserved ejection fraction (HFpEF) is uncertain. Objective To investigate whether catheter ablation for AF is associated with reduced HF-related outcomes according to HF phenotype. Data Source A systematic search of MEDLINE, Embase, and Cochrane Central was conducted among studies published from inception to September 2023. Study Selection Parallel-group randomized clinical trials (RCTs) comparing catheter ablation with conventional rate or rhythm control therapies in patients with HF, New York Heart Association functional class II or greater, and a history of paroxysmal or persistent AF were included. Pairs of independent reviewers screened 7531 titles and abstracts, of which 12 RCTs and 4 substudies met selection criteria. Data Extraction and Synthesis Data were abstracted in duplicate according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Pooled effect estimates were calculated using random-effects Mantel-Haenszel models. Interaction P values were used to test for subgroup differences. Main Outcomes and Measures The primary outcome was HF events, defined as HF hospitalization, clinically significant worsening of HF, or unscheduled visits to a clinician for treatment intensification. Secondary outcomes included cardiovascular and all-cause mortality. Results A total of 12 RCTs with 2465 participants (mean [SD] age, 65.3 [9.7] years; 658 females [26.7%]) were included; there were 1552 participants with HFrEF and 913 participants with HFpEF. Compared with conventional rate or rhythm control, catheter ablation was associated with reduced risk of HF events in HFrEF (risk ratio [RR], 0.59; 95% CI, 0.48-0.72), while there was no benefit in patients with HFpEF (RR, 0.93; 95% CI, 0.65-1.32) (P for interaction = .03). Catheter ablation was associated with reduced risk of cardiovascular death compared with conventional therapies in HFrEF (RR, 0.49; 95% CI, 0.34-0.70) but a differential association was not detected in HFpEF (RR, 0.91; 95% CI, 0.46-1.79) (P for interaction = .12). Similarly, no difference in the association of catheter ablation with all-cause mortality was found between HFrEF (RR vs conventional therapies, 0.63; 95% CI, 0.47-0.86) and HFpEF (RR vs conventional therapies, 0.95; 95% CI, 0.39-2.30) groups (P for interaction = .39). Conclusions and Relevance This study found that catheter ablation for AF was associated with reduced risk of HF events in patients with HFrEF but had limited or no benefit in HFpEF. Results from ongoing trials may further elucidate the role of catheter ablation for AF in HFpEF.
Collapse
Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - William F. McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ratika Parkash
- Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada
| | - Krzysztof Kowalik
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ghazal Razeghi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Emilie P. Belley-Côté
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Conen
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J. Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anthony S. L. Tang
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jeff S. Healey
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A. Wong
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
4
|
Chuang HJ, Lin LC, Yu AL, Liu YB, Lin LY, Huang HC, Ho LT, Lai LP, Chen WJ, Ho YL, Chen SY, Yu CC. Predicting impaired cardiopulmonary exercise capacity in patients with atrial fibrillation using a simple echocardiographic marker. Heart Rhythm 2024:S1547-5271(24)02375-0. [PMID: 38614190 DOI: 10.1016/j.hrthm.2024.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/23/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Exercise intolerance is a common symptom associated with atrial fibrillation (AF). However, echocardiographic markers that can predict impaired exercise capacity are lacking. OBJECTIVE This study aimed to investigate the association between echocardiographic parameters and exercise capacity assessed by cardiopulmonary exercise testing in patients with AF. METHODS This single-center prospective study enrolled patients with AF who underwent echocardiography and cardiopulmonary exercise testing to evaluate exercise capacity at a tertiary center for AF management from 2020 to 2022. Patients with valvular heart disease, reduced left ventricular ejection fraction, or documented cardiomyopathy were excluded. RESULTS Of the 188 patients, 134 (71.2%) exhibited impaired exercise capacity (peak oxygen consumption ≤85%), including 4 (2.1%) having poor exercise capacity (peak oxygen consumption <50%). Echocardiographic findings revealed that these patients had an enlarged left atrial end-systolic diameter (LA); smaller left ventricular end-diastolic diameter (LVEDD); and increased relative wall thickness, tricuspid regurgitation velocity, and LA/LVEDD and E/e' ratios. In addition, they exhibited lower peak systolic velocity of the mitral annulus and LA reservoir strain. In the multivariate regression model, LA/LVEDD remained the only significant echocardiographic parameter after adjustment for age, sex, and body mass index (P = .020). This significance persisted even after incorporation of heart rate reserve, N-terminal pro-B-type natriuretic peptide level, and beta-blocker use into the model. CONCLUSION In patients with AF, LA/LVEDD is strongly associated with exercise capacity. Further follow-up and validation are necessary to clarify its clinical implications in patient care.
Collapse
Affiliation(s)
- Hung-Jui Chuang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Lung-Chun Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - An-Li Yu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-chu Branch, Hsinchu, Taiwan
| | - Yen-Bin Liu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hui-Chun Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Li-Ting Ho
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ling-Ping Lai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Yi-Lwung Ho
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ssu-Yuan Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan; Division of Physical Medicine and Rehabilitation, Fu Jen Catholic University Hospital and Fu Jen Catholic University School of Medicine, New Taipei City, Taiwan
| | - Chih-Chieh Yu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
| |
Collapse
|
5
|
Kroshian G, Joseph J, Kinlay S, Peralta AO, Hoffmeister PS, Singh JP, Yuyun MF. Atrial fibrillation and risk of adverse outcomes in heart failure with reduced, mildly reduced, and preserved ejection fraction: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2024; 35:715-726. [PMID: 38348517 DOI: 10.1111/jce.16209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/03/2024] [Accepted: 01/28/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Heart failure (HF) and atrial fibrillation (AF) frequently co-exist. Contemporary classification of HF categorizes it into HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF). Aggregate data comparing the risk profile of AF between these three HF categories are lacking. METHODS We conducted a systematic review and meta-analysis aimed at determining any significant differences in AF-associated all-cause mortality, HF hospitalizations, cardiovascular mortality (CV), and stroke between HFrEF, HFmrEF, and HFpEF. A systematic search of PubMed, EMBASE, and Cochrane Library databases until February 28, 2023. Data were combined using DerSimonian-Laird random effects model. RESULTS A total of 22 studies comprising 248 323 patients were retained: HFrEF 123 331 (49.7%), HFmrEF 40 995 (16.5%), and HFpEF 83 997 (33.8%). Pooled baseline AF prevalence was 36% total population, 30% HFrEF, 36% HFmrEF, and 42% HFpEF. AF was associated with a higher risk of all-cause mortality in the total population with pooled hazard ratio (HR) = 1.13 (95% confidence interval [CI] = 1.07-1.21), HFmrEF (HR = 1.25, 95% CI = 1.05-1.50) and HFpEF (HR = 1.16, 95% CI = 1.09-1.24), but not HFrEF (HR = 1.03, 95% CI = 0.93-1.14). AF was associated with a higher risk of HF hospitalizations in the total population (HR = 1.29, 95% CI = 1.14-1.46), HFmrEF (HR = 1.64, 95% CI = 1.20-2.24), and HFpEF (HR = 1.46, 95% CI = 1.17-1.83), but not HFrEF (HR = 1.01, 95% CI = 0.87-1.18). AF was only associated with CV in the HFpEF subcategory but was associated with stroke in all three HF subtypes. CONCLUSIONS AF appears to be associated with a higher risk of all-cause mortality and HF hospitalization in HFmrEF and HFpEF. With these findings, the paucity of data and treatment guidelines on AF in the HFmrEF subgroup becomes even more significant and warrant further investigations.
Collapse
Affiliation(s)
- Garen Kroshian
- Boston University Chobanian and Avedisian School of Medicine, Boston, USA
| | - Jacob Joseph
- VA Providence Healthcare System, Providence, Rhode Island, USA
- Department of Medicine, Brown University, Providence, Rhode Island, USA
- VA Boston Healthcare System, Boston, USA
| | - Scott Kinlay
- Boston University Chobanian and Avedisian School of Medicine, Boston, USA
- VA Boston Healthcare System, Boston, USA
- Harvard Medical School, Boston, USA
- Brigham and Women's Hospital, Boston, USA
| | - Adelqui O Peralta
- Boston University Chobanian and Avedisian School of Medicine, Boston, USA
- VA Boston Healthcare System, Boston, USA
- Harvard Medical School, Boston, USA
| | - Peter S Hoffmeister
- Boston University Chobanian and Avedisian School of Medicine, Boston, USA
- VA Boston Healthcare System, Boston, USA
- Harvard Medical School, Boston, USA
| | - Jagmeet P Singh
- Harvard Medical School, Boston, USA
- Massachusetts General Hospital, Boston, USA
| | - Matthew F Yuyun
- Boston University Chobanian and Avedisian School of Medicine, Boston, USA
- VA Boston Healthcare System, Boston, USA
- Harvard Medical School, Boston, USA
| |
Collapse
|
6
|
Karaban K, Słupik D, Reda A, Gajewska M, Rolek B, Borovac JA, Papakonstantinou PE, Bongiovanni D, Ehrlinder H, Parker WAE, Siniarski A, Gąsecka A. Coagulation Disorders and Thrombotic Complications in Heart Failure With Preserved Ejection Fraction. Curr Probl Cardiol 2024; 49:102127. [PMID: 37802171 DOI: 10.1016/j.cpcardiol.2023.102127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is associated with multiple cardiovascular and noncardiovascular comorbidities and risk factors which increase the risk of thrombotic complications, such as atrial fibrillation, chronic kidney disease, arterial hypertension and type 2 diabetes mellitus. Subsequently, thromboembolic risk stratification in this population poses a great challenge. Since date from the large randomized clinical trials mostly include both patients with truly preserved EF, and those with heart failure with mildly reduced ejection fraction, there is an unmet need to characterize the patients with truly preserved EF. Considering the significant evidence gap in this area, we sought to describe the coagulation disorders and thrombotic complications in patients with HFpEF and discuss the specific thromboembolic risk factors in patients with HFpEF, with the goal to tailor risk stratification to an individual patient.
Collapse
Affiliation(s)
- Kacper Karaban
- Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Słupik
- Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Aleksandra Reda
- Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Gajewska
- Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Bartosz Rolek
- Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Josip A Borovac
- Division of Interventional Cardiology, Cardiovascular Diseases Department, University Hospital of Split, Split, Croatia
| | - Panteleimon E Papakonstantinou
- Second Cardiology Department, Evangelismos Hospital, Athens, Greece; First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dario Bongiovanni
- Department of Internal Medicine I, Cardiology, University Hospital Augsburg, University of Augsburg, Augsburg, Germany; Department of Cardiovascular Medicine, Humanitas Clinical and Research Center IRCCS and Humanitas University, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Cardiovascular Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Hanne Ehrlinder
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - William A E Parker
- Cardiovascular Research Unit, Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Aleksander Siniarski
- Department of Coronary Artery Disease and Heart Failure, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, Cracow, Poland; John Paul II Hospital, Cracow, Poland
| | - Aleksandra Gąsecka
- Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.
| |
Collapse
|
7
|
Dye C, Dela Cruz M, Larsen T, Nair G, Marinescu K, Suboc T, Engelstein E, Marsidi J, Patel P, Sharma P, Volgman AS. A review of the impact, pathophysiology, and management of atrial fibrillation in patients with heart failure with preserved ejection fraction. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 33:100309. [PMID: 38510554 PMCID: PMC10946048 DOI: 10.1016/j.ahjo.2023.100309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 07/11/2023] [Indexed: 03/22/2024]
Abstract
Patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) have increased mortality and increased risk of stroke. Due to the heterogeneous nature of both disease processes, it is difficult to ascertain whether the diagnosis and progression of AF is the cause of deterioration or if it is a symptom of worsening heart failure. This presents physicians with a clinical conundrum of whether optimizing their heart failure will decrease the overall AF burden or if restoration of sinus rhythm is necessary to optimize patients with HFpEF. In this paper, we will review the impact of AF in patients with HFpEF, the pathophysiology and heterogeneity of HFpEF and AF, and the management of these patients. As HFpEF and AF become more prevalent, managing these disease processes needs standardization to improve outcomes. Further research is needed to understand the complex interplay between AF and HFpEF to help determine the best management strategy.
Collapse
Affiliation(s)
- Cicely Dye
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Mark Dela Cruz
- Advocate Heart Institute, Advocate Christ Medical Center, Chicago, IL 60453, USA
| | - Timothy Larsen
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Gatha Nair
- Division of Cardiology, University of Washington, Seattle, WA 98105, USA
| | - Karolina Marinescu
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Tisha Suboc
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Erica Engelstein
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Jennifer Marsidi
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Priya Patel
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Parikshit Sharma
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | | |
Collapse
|
8
|
Lin MS, Wang PC, Lin MH, Kuo TY, Lin YS, Chen TH, Tsai MH, Yang YH, Lin CL, Chung CM, Chu PH. Acute heart failure with mildly reduced ejection fraction and myocardial infarction: a multi-institutional cohort study. BMC Cardiovasc Disord 2023; 23:272. [PMID: 37221514 DOI: 10.1186/s12872-023-03286-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/09/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Little research has been done on ischemic outcomes related to left ventricular ejection fraction (EF) in acute decompensated heart failure (ADHF). METHODS A retrospective cohort study was conducted between 2001 and 2021 using the Chang Gung Research Database. ADHF Patients discharged from hospitals between January 1, 2005, and December 31, 2019. Cardiovascular (CV) mortality and heart failure (HF) rehospitalization are the primary outcome components, along with all-cause mortality, acute myocardial infarction (AMI) and stroke. RESULTS A total of 12,852 ADHF patients were identified, of whom 2,222 (17.3%) had HFmrEF, the mean (SD) age was 68.5 (14.6) years, and 1,327 (59.7%) were males. In comparison with HFrEF and HFpEF patients, HFmrEF patients had a significant phenotype comorbid with diabetes, dyslipidemia, and ischemic heart disease. Patients with HFmrEF were more likely to experience renal failure, dialysis, and replacement. Both HFmrEF and HFrEF had similar rates of cardioversion and coronary interventions. There was an intermediate clinical outcome between HFpEF and HFrEF, but HFmrEF had the highest rate of AMI (HFpEF, 9.3%; HFmrEF, 13.6%; HFrEF, 9.9%). The AMI rates in HFmrEF were higher than those in HFpEF (AHR, 1.15; 95% Confidence Interval, 0.99 to 1.32) but not in HFrEF (AHR, 0.99; 95% Confidence Interval, 0.87 to 1.13). CONCLUSION Acute decompression in patients with HFmrEF increases the risk of myocardial infarction. The relationship between HFmrEF and ischemic cardiomyopathy, as well as optimal anti-ischemic treatment, requires further research on a large scale.
Collapse
Affiliation(s)
- Ming-Shyan Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Po-Chang Wang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
| | - Meng-Hung Lin
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
| | - Ting-Yu Kuo
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
| | - Yu-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
| | - Tien-Hsing Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chiayi Branch, Keelung, Taiwan
| | - Ming-Horng Tsai
- Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan
| | - Yao-Hsu Yang
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Liang Lin
- Department of Nephrology, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
| | - Chang-Min Chung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Linkou Branch, No.5, Fu-Hsing Street, Gueishan District, Taoyuan, 33305, Taiwan.
- Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital Chang Gung University College of Medicine, Taipei, Taiwan.
| |
Collapse
|
9
|
Guo L, Liu X, Yu P, Zhu W. The "Obesity Paradox" in Patients With HFpEF With or Without Comorbid Atrial Fibrillation. Front Cardiovasc Med 2022; 8:743327. [PMID: 35087875 PMCID: PMC8787078 DOI: 10.3389/fcvm.2021.743327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 11/24/2021] [Indexed: 01/22/2023] Open
Abstract
Background: Overweight and mildly obese individuals have a lower risk of death than their normal-weight counterparts; this phenomenon is termed "obesity paradox." Whether this "obesity paradox" exists in patients with heart failure (HF) or can be modified by comorbidities is still controversial. Our current study aimed to determine the association of body mass index (BMI) with outcomes with patients with HF with preserved ejection fraction (HFpEF) with or without coexisting atrial fibrillation (AF). Methods: Patients with HFpEF from the Americas in the TOPCAT trial were categorized into the 3 groups: normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obesity (≥30 kg/m2). The Cox proportional-hazards models were used to calculate the adjusted hazard ratios (HRs) and CIs. Results: We identified 1,749 patients with HFpEF, 42.1% of which had baseline AF. In the total population of HFpEF, both overweight (HR = 0.59, 95% CI: 0.42-0.83) and obesity (HR = 0.49, 95% CI: 0.35-0.69) were associated with a reduced risk of all-cause death. Among patients with HFpEF without AF, overweight (HR = 0.51, 95% CI: 0.27-0.95) and obesity (HR = 0.64, 95% CI: 0.43-0.98) were associated with a lower risk of all-cause death. In those with AF, obesity (HR = 0.62, 95% CI: 0.40-0.95) but not overweight (HR = 0.81, 95% CI: 0.54-1.21) was associated with a decreased risk of all-cause death. Conclusions: The "obesity paradox" assessed by BMI exists in patients with HFpEF regardless of comorbid AF. Clinical Trial Registration: https://clinicaltrials.gov, identifier: NCT00094302.
Collapse
Affiliation(s)
- Linjuan Guo
- Department of Cardiology, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China
| | - Xiao Liu
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Peng Yu
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| |
Collapse
|
10
|
Liang M, Bian B, Yang Q. Characteristics and long-term prognosis of patients with reduced, mid-range, and preserved ejection fraction: A systemic review and meta-analysis. Clin Cardiol 2022; 45:5-17. [PMID: 35043472 PMCID: PMC8799045 DOI: 10.1002/clc.23754] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/11/2021] [Accepted: 11/19/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS Patients with heart failure (HF) have a poor prognosis and are categorized by ejection fraction. We performed a meta-analysis to compare baseline characteristics and long-term outcomes of patients with heart failure with reduced (HFrEF), mid-range (HFmrEF), and preserved ejection fraction (HFpEF). METHODS AND RESULTS A total of 27 prospective studies were included. Patients with HFpEF were older and had a higher proportion of females, hypertension, diabetes, and insufficient neuroendocrine antagonist treatments, while patients with HFrEF and HFmrEF had a higher prevalence of coronary heart disease and chronic kidney disease. After more than 1-year of follow-up, all-cause mortality was significantly lower in patients with HFmrEF 9388/25 042 (37.49%) than those with HFrEF 39 333/90 023 (43.69%) and HFpEF 24 828/52 492 (47.30%) (p < .001). Cardiovascular mortality was lowest in patients with HFpEF 1130/9904 (11.41%), highest in patients with HFrEF 3419/16 277 (21.07%) mainly coming from HF death and sudden cardiac death, and middle in patients with HFmrEF 699/5171 (13.52%) and the non-cardiovascular mortality was on the contrary. Subgroup analysis showed that in high-risk patients with atrial fibrillation, the all-cause mortality of HFpEF was significantly higher than both HFrEF and HFmrEF (p < .001). HF hospitalization was lowest in patients with HFmrEF 1822/5285 (34.47%), highest in patients with HFrEF 12 607/28 590 (44.10%) and middle in patients with HFpEF 8686/22 763 (38.16%) and the composite of all-cause mortality and HF hospitalization was also observed similar results. CONCLUSIONS In summary, patients with HFmrEF had the lowest incidence of all-cause mortality and HF hospitalization, while the highest all-cause mortality and HF hospitalization rates were HFpEF and HFrEF patients, respectively.
Collapse
Affiliation(s)
- Min Liang
- Department of CardiologyTianjin Medical University General HospitalTianjinPeople's Republic of China
| | - Bo Bian
- Department of CardiologyTianjin Medical University General HospitalTianjinPeople's Republic of China
| | - Qing Yang
- Department of CardiologyTianjin Medical University General HospitalTianjinPeople's Republic of China
| |
Collapse
|
11
|
Ariyaratnam JP, Elliott AD, Mishima RS, Gallagher C, Lau DH, Sanders P. Heart failure with preserved ejection fraction: An alternative paradigm to explain the clinical implications of atrial fibrillation. Heart Rhythm O2 2021; 2:771-783. [PMID: 34988529 PMCID: PMC8710629 DOI: 10.1016/j.hroo.2021.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Atrial fibrillation (AF) is associated with exercise intolerance, stroke, and all-cause mortality. However, whether this can be solely attributable to the arrhythmia itself or alternative mechanisms remains controversial. Heart failure with preserved ejection (HFpEF) commonly coexists with AF and may contribute to the poor outcomes associated with AF. Indeed, several invasive hemodynamic studies have confirmed that patients with AF are at increased risk of underlying HFpEF and that the presence of HFpEF may have important prognostic implications in these patients. Mechanistically, AF and HFpEF are closely linked. Both conditions are driven by the presence of common cardiovascular risk factors and are associated with left atrial (LA) myopathy, characterized by mechanical and electrical dysfunction. Progressive worsening of this left atrial (LA) myopathy is associated with both increased AF burden and worsening HFpEF. In addition, there is growing evidence to suggest that worsening LA myopathy is associated with poorer outcomes in both conditions and that reversal of the LA myopathy could improve outcomes. In this review article, we will present the epidemiologic and mechanistic evidence underlying the common coexistence of AF and HFpEF, discuss the importance of a progressive LA myopathy in the pathogenesis of both conditions, and review the evidence from important invasive hemodynamic studies. Finally, we will review the prognostic implications of HFpEF in patients with AF and discuss the relative merits of AF burden reduction vs HFpEF reduction in improving outcomes of patients with AF and HFpEF.
Collapse
Affiliation(s)
- Jonathan P Ariyaratnam
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Ricardo S Mishima
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| |
Collapse
|
12
|
Lejeune S, Roy C, Slimani A, Pasquet A, Vancraeynest D, Vanoverschelde JL, Gerber BL, Beauloye C, Pouleur AC. Diabetic phenotype and prognosis of patients with heart failure and preserved ejection fraction in a real life cohort. Cardiovasc Diabetol 2021; 20:48. [PMID: 33608002 PMCID: PMC7893869 DOI: 10.1186/s12933-021-01242-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/08/2021] [Indexed: 12/29/2022] Open
Abstract
Background Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome, with several underlying etiologic and pathophysiologic factors. The presence of diabetes might identify an important phenotype, with implications for therapeutic strategies. While diabetes is associated with worse prognosis in HFpEF, the prognostic impact of glycemic control is yet unknown. Hence, we investigated phenotypic differences between diabetic and non-diabetic HFpEF patients (pts), and the prognostic impact of glycated hemoglobin (HbA1C). Methods We prospectively enrolled 183 pts with HFpEF (78 ± 9 years, 38% men), including 70 (38%) diabetics (type 2 diabetes only). They underwent 2D echocardiography (n = 183), cardiac magnetic resonance (CMR) (n = 150), and were followed for a combined outcome of all-cause mortality and first HF hospitalization. The prognostic impact of diabetes and glycemic control were determined with Cox proportional hazard models, and illustrated by adjusted Kaplan Meier curves. Results Diabetic HFpEF pts were younger (76 ± 9 vs 80 ± 8 years, p = 0.002), more obese (BMI 31 ± 6 vs 27 ± 6 kg/m2, p = 0.001) and suffered more frequently from sleep apnea (18% vs 7%, p = 0.032). Atrial fibrillation, however, was more frequent in non-diabetic pts (69% vs 53%, p = 0.028). Although no echocardiographic difference could be detected, CMR analysis revealed a trend towards higher LV mass (66 ± 18 vs 71 ± 14 g/m2, p = 0.07) and higher levels of fibrosis (53% vs 36% of patients had ECV by T1 mapping > 33%, p = 0.05) in diabetic patients. Over 25 ± 12 months, 111 HFpEF pts (63%) reached the combined outcome (24 deaths and 87 HF hospitalizations). Diabetes was a significant predictor of mortality and hospitalization for heart failure (HR: 1.72 [1.1–2.6], p = 0.011, adjusted for age, BMI, NYHA class and renal function). In diabetic patients, lower levels of glycated hemoglobin (HbA1C < 7%) were associated with worse prognosis (HR: 2.07 [1.1–4.0], p = 0.028 adjusted for age, BMI, hemoglobin and NT-proBNP levels). Conclusion Our study highlights phenotypic features characterizing diabetic patients with HFpEF. Notably, they are younger and more obese than their non-diabetic counterpart, but suffer less from atrial fibrillation. Although diabetes is a predictor of poor outcome in HFpEF, intensive glycemic control (HbA1C < 7%) in diabetic patients is associated with worse prognosis.
Collapse
Affiliation(s)
- Sibille Lejeune
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc and Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Cardiovascular Division, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium
| | - Clotilde Roy
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc and Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Cardiovascular Division, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium
| | - Alisson Slimani
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc and Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Cardiovascular Division, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium
| | - Agnès Pasquet
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc and Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Cardiovascular Division, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium
| | - David Vancraeynest
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc and Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Cardiovascular Division, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium
| | - Jean-Louis Vanoverschelde
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc and Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Cardiovascular Division, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium
| | - Bernhard L Gerber
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc and Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Cardiovascular Division, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium
| | - Christophe Beauloye
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc and Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Cardiovascular Division, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium
| | - Anne-Catherine Pouleur
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc and Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Cardiovascular Division, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium.
| |
Collapse
|