Arrhythmia care in ESC member countries: the 2025 ESC-EHRA atlas on heart rhythm disorders

Abstract

The ESC-EHRA Atlas on Heart Rhythm Disorders was developed to comprehensively map arrhythmia care across the European Society of Cardiology (ESC) member countries. A survey of National Cardiac Societies, Working Groups, and other EHRA partners in ESC member countries was conducted to gather data from 2023 or the most recently available year on arrhythmia care organization and delivery. In total, 51 ESC member countries actively participated in the study, with a survey completeness rate of 91%. The median number of hospitals performing EP or CIED procedures was 3.3 per million people. The annual median numbers of ablation procedures for heart rhythm disorders, atrial fibrillation, and supraventricular tachycardia per million people were 432, 151, and 136, respectively. The annual median numbers of pacemakers, implantable cardioverter-defibrillators (ICD), and cardiac resynchronization therapy cardioverter-defibrillator (CRT-D) implantations per million people were 739, 195, and 54, respectively. The median number of hospitals performing remote monitoring of CIEDs per million people was 0.5, though this service was unavailable in 15 countries. Two main universal issues emerged among the obstacles to guideline implementation: a lack of heart rhythm allied professionals and general dissatisfaction with the country's reimbursement system. The first edition of the ESC-EHRA Atlas presents up-to-date information on arrhythmia care organization and delivery among ESC member countries and highlights significant discrepancies in patients' access to ESC-guideline-recommended therapies.

Keywords: Ablation; Arrhythmia; Cardiac pacemakers; European Society of Cardiology; Health economics; Health infrastructure; Implantable cardiac defibrillators; Reimbursement; Statistics.

Graphical Abstract

Figure 1

The number of hospitals per million people in each country that perform electrophysiology procedures for diagnostic or interventional purposes or implant cardiac electronic devices. Malta, Montenegro, and Republic of San Marino reported only one hospital.

Figure 2

Number of operators in electrophysiology, cardiac implantable electronic devices, and transvenous lead extraction, per million people by country. EP operators. Republic of Kosovo reported 0 while Republic of San Marino reported only one EP operator. Missing data: Italy, UK. CIED operators. Missing data: Belgium, Netherlands, UK. Republic of San Marino reported 0 CIED operators. Transvenous lead extraction operators. Algeria, Armenia, Bosnia and Herzegovina, Iceland, Republic of Kosovo, North Macedonia, Montenegro, and Republic of San Marino reported 0 TLE operators. Missing data: Algeria, Ireland, Luxembourg, Portugal, UK.

Figure 3

Numbers of fellows in electrophysiology, cardiac implantable electronic devices, and transvenous lead extraction per million people by country. EP fellows. Cyprus, Iceland, Lebanon, Lithuania, Luxembourg, Republic of Moldova, and Türkiye reported 0 EP fellows. Missing data: Czechia, Denmark, Ireland, Portugal, Republic of San Marino, UK. CIED fellows. Cyprus, Iceland, Lebanon, Lithuania, Luxembourg, and Republic of San Marino, and Türkiye reported 0 CIED fellows. Missing data: Austria, Belgium, Czechia, Denmark, Ireland, Netherlands, Portugal, UK. Lead extracting fellows. Armenia, Bosnia and Herzegovina, Cyprus, Estonia, Georgia, Iceland, Israel, Republic of Kosovo, Kyrgyzstan, Lebanon, Lithuania, Luxembourg, Republic of Moldova, Montenegro, Romania, Republic of San Marino, Serbia, Slovakia, and Türkiye reported 0 TLE fellows. Missing data: Belgium, Bulgaria, Croatia, Denmark, France, Ireland, Italy, Kazakhstan, Netherlands, Portugal, Spain, Tunisia, and UK.

Figure 4

Number of hospitals by country performing 100 or more of any ablations for heart rhythm disorders per million people and those performing 50 or more of AF ablations per million people. Hospital undertaking ≥100 any ablations per year. Republic of Kosovo, Malta, Republic of San Marino reported 0 while Algeria, Cyprus, Iceland, Latvia, Luxembourg, Montenegro, and North Macedonia reported only one hospital. Missing data: Italy. Hospital undertaking ≥50 AF ablations/year. Algeria, Armenia, Republic of Kosovo, North Macedonia, Malta, Republic of Moldova, Montenegro, Republic of San Marino reported 0 while Azerbaijan, Bosnia & Herzegovina, Cyprus, Iceland, Kyrgyzstan, Latvia, and Luxembourg reported only one hospital. Missing data: Italy, Tunisia.

Figure 5

Number of ablation procedures for heart rhythm disorders per million people by country (A), number of AF ablations per million people by country (B). Ablations to correct heart rhythm disorders. Republic of San Marino reported 0 ablations. Missing data: Azerbaijan, Ireland, Kazakhstan, Tunisia. AF Ablations. Republic of Kosovo and Republic of San Marino reported 0 AF ablations. Missing data: Ireland, Tunisia. * Belgium reported AF and other complex left atrial ablations together, in accordance with national rules on procedure reporting for reimbursement.

Figure 6

Number of pacemaker implantations regardless of type or indication. Missing data: Republic of San Marino.

Figure 7

Number of leadless pacemaker implantations per million people by country (A), and number of conduction system pacing stimulator implantations per million people by country (B). Leadless pacemakers. Algeria, Armenia, Azerbaijan, Bosnia and Herzegovina, Estonia, Georgia, Iceland, Republic of Kosovo, Kyrgyzstan, Republic of Moldova, Portugal, Tunisia, and Uzbekistan reported 0 leadless pacemaker implantations. Missing data: Belgium, Ireland, Netherlands, Republic of San Marino. CSP Pacemakers. Reported value zero: Algeria, Azerbaijan, Bosnia and Herzegovina, Cyprus, Georgia, Lithuania, Montenegro, and Uzbekistan reported 0 CSP pacemaker implantations. Missing data: Luxembourg, Austria, Belgium, Denmark, Ireland, Netherlands, Norway, Portugal, Republic of San Marino, UK.

Figure 8

Number of conventional implantable cardioverter-defibrillators implanted per million people by country (A), and the number of subcutaneous/extravascular cardioverter-defibrillators implanted per million people by country (B). Conventional ICDs. Missing data: Ireland, Republic of San Marino. Subcutaneous/extravascular ICDs. Algeria, Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria, Egypt, Estonia, Iceland, Republic of Kosovo, Kyrgyzstan, Lithuania, North Macedonia, Republic of Moldova, Montenegro, Ukraine, and Uzbekistan reported 0 implantations of subcutaneous/extravascular ICDs. Missing data: Ireland, Italy, Republic of San Marino.

Figure 9

Number of hospitals per one million people that perform remote monitoring of cardiac implantable electronic devices. Algeria, Armenia, Azerbaijan, Bosnia and Herzegovina, Egypt, Georgia, Republic of Kosovo, Kyrgyzstan, Lebanon, Lithuania, Luxembourg, Montenegro, Republic of Moldova, Tunisia, Türkiye, Ukraine, Uzbekistan reported 0 while Cyprus, Iceland, Malta, North Macedonia reported only one hospital. Missing data: Austria, Belgium, Ireland, Italy, Netherlands, Republic of San Marino, UK.

Figure 10

Types of national community training programmes in basic or advanced life support. All survey participants replied.

Figure 11

Perceived lack of electrophysiology or cardiac implantable electronic devices operators. Missing data: Republic of Moldova, UK.