Access to cardiac implantable electronic device therapy in the European Society of Cardiology EuroAsia region: a comparative analysis of implantation activity, infrastructure, and health financing

AIMS: Access to cardiac implantable electronic device (CIED) therapy varies substantially across Europe, yet data from the ESC EuroAsia region remain limited. We aimed to compare implantation activity of pacemakers (PM), implantable cardioverter-defibrillators (ICD), and cardiac resynchronization therapy (CRT) devices across ESC EuroAsia Task Force (TF) countries, and to examine how infrastructure, workforce capacity, and health financing patterns relate to device uptake. METHODS: National-level aggregated data were collected in 2025 through a standardized ESC EuroAsia TF survey and contextualized using EHRA Atlas indicators and World Bank/WHO health expenditure data. Implantation rates per million population were compared across Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Turkmenistan, and Uzbekistan. RESULTS: Pacemaker implantation showed moderate variability (21-333 per million), whereas ICD (0.1-172 per million) and particularly CRT (1-135 per million) implantation demonstrated pronounced disparities. Countries with higher density of implanting centers and greater electrophysiology workforce availability-most notably Georgia-had substantially higher per-capita ICD and CRT implantation rates. Exploratory analyses suggested moderate positive correlations between national health expenditure (%GDP) and ICD and CRT implantation rates, whereas financing structure (out-of-pocket vs. government share) showed no consistent association. CONCLUSION: CIED implantation activity in the ESC EuroAsia region follows a clear complexity gradient (PM > ICD > CRT), indicating that access to advanced device therapy is primarily determined by system capacity rather than guideline awareness alone. Strengthening predictable reimbursement pathways, structured referral networks, workforce development, and national registries may reduce inequities and narrow the evidence-practice gap in sudden cardiac death prevention and heart failure management.