Access to CIED Therapy in the ESC EuroAsia Region: Comparative Analysis of Implantation, Infrastructure, and Financing
The authors set out to compare national-level implantation activity for cardiac implantable electronic devices (CIEDs) — specifically pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices — across countries in the European Society of Cardiology (ESC) EuroAsia Task Force (TF). The analysis also examined how health system factors, including infrastructure, workforce capacity, and financing patterns, relate to device uptake.
Aggregated national data were collected in 2025 through a standardized ESC EuroAsia TF survey. These survey data were contextualized using indicators from the European Heart Rhythm Association (EHRA) Atlas and health expenditure data from the World Bank and World Health Organization. Implantation rates were expressed per million population and compared across seven TF countries: Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Turkmenistan, and Uzbekistan.
Measured implantation activity displayed a clear gradient of complexity across device types. Pacemaker implantation rates showed moderate variability across the assessed countries, ranging from 21 to 333 implants per million population. In contrast, implantation rates for ICDs and CRT devices exhibited much larger disparities: ICD rates ranged from 0.1 to 172 per million, while CRT rates ranged from 1 to 135 per million.
This distribution indicates that simpler device therapy (PM) is more uniformly available than more complex therapies (ICD and CRT), with the latter showing pronounced inequality in access between countries within the ESC EuroAsia region.
Countries with a higher density of implanting centres and greater availability of electrophysiology-trained workforce had substantially higher per-capita implantation rates for ICD and CRT devices. The report identifies Georgia as an example of a country with notably greater system capacity, which corresponded with higher ICD and CRT uptake compared with other TF countries.
The study underscores that procedural complexity and system requirements — including the number and distribution of implanting centres and trained staff — are key determinants of whether advanced device therapies are delivered at scale.
Exploratory analyses in the survey suggested a moderate positive correlation between national health expenditure (expressed as a percentage of gross domestic product) and ICD and CRT implantation rates. This suggests that countries investing a larger share of their national income in health tended to have higher uptake of advanced device therapies.
By contrast, the structure of financing — specifically the relative shares of out-of-pocket payments versus government financing — did not show a consistent association with implantation activity across the evaluated countries. The absence of a clear pattern indicates that financing modality alone does not fully explain differences in access to ICD and CRT therapy in the ESC EuroAsia region.
Across ESC EuroAsia TF countries, device implantation activity followed a complexity gradient: PM > ICD > CRT. The authors interpret this pattern as evidence that access to advanced device therapy is determined primarily by health system capacity (infrastructure and workforce) rather than by guideline awareness alone.
This interpretation emphasizes that even where clinical guidelines support use of ICD and CRT, real-world implementation depends on having the necessary centres, trained personnel, and health system resources to deliver these therapies.
Based on the findings, the authors recommend health system actions to reduce inequities in access to CIED therapy. Key suggested measures include:
These measures are proposed to narrow the evidence-practice gap in prevention of sudden cardiac death and management of heart failure.
The report is based on aggregated national-level data collected via survey in 2025 and contextualized using available EHRA Atlas and World Bank/WHO data. Specific methodological details, country-level numeric breakdowns beyond the reported ranges, and other granular data were not included in the abstract. Conflict of interest was declared as none.