Statement from the Asia Summit: Current state of arrhythmia care in Asia

On May 27, 2022, the Asia Pacific Heart Rhythm Society and the Heart Rhythm Society convened a meeting of leaders from different professional societies of healthcare providers committed to arrhythmia care from the Asia Pacific region. The overriding goals of the meeting were to discuss clinical and health policy issues that face each country for providing care for patients with electrophysiologic issues, share experiences and best practices, and discuss potential future solutions. Participants were asked to address a series of questions in preparation for the meeting. The format of the meeting was a series of individual country reports presented by the leaders from each of the professional societies followed by open discussion. The recorded presentations from the Asia Summit can be accessed at https://www.heartrhythm365.org/URL/asiasummit-22. Three major themes arose from the discussion. First, the major clinical problems faced by different countries vary. Although atrial fibrillation is common throughout the region, the most important issues also include more general issues such as hypertension, rheumatic heart disease, tobacco abuse, and management of potentially life-threatening problems such as sudden cardiac arrest or profound bradycardia. Second, there is significant variability in the access to advanced arrhythmia care throughout the region due to differences in workforce availability, resources, drug availability, and national health policies. Third, collaboration in the area already occurs between individual countries, but no systematic regional method for working together is present. On May 27, 2022, the Asia Pacific Heart Rhythm Society and the Heart Rhythm Society convened a meeting of leaders from different professional societies of healthcare providers committed to arrhythmia care from the Asia Pacific region. The overriding goals of the meeting were to discuss clinical and health policy issues that face each country for providing care for patients with electrophysiologic issues, share experiences and best practices, and discuss potential future solutions. Participants were asked to address a series of questions in preparation for the meeting. The format of the meeting was a series of individual country reports presented by the leaders from each of the professional societies followed by open discussion. The recorded presentations from the Asia Summit can be accessed at https://www.heartrhythm365.org/URL/asiasummit-22. Three major themes arose from the discussion. First, the major clinical problems faced by different countries vary. Although atrial fibrillation is common throughout the region, the most important issues also include more general issues such as hypertension, rheumatic heart disease, tobacco abuse, and management of potentially life-threatening problems such as sudden cardiac arrest or profound bradycardia. Second, there is significant variability in the access to advanced arrhythmia care throughout the region due to differences in workforce availability, resources, drug availability, and national health policies. Third, collaboration in the area already occurs between individual countries, but no systematic regional method for working together is present. The Asia Pacific region is a large and diverse group of countries usually defined as those countries on the western side of the Pacific Ocean and is often further subdivided into East Asia, North Asia, Southeast Asia, Oceania (Australasia, Polynesia, Micronesia, Melanesia), and the Indian subcontinent.1Cambridge DictionaryAsian Pacific.https://dictionary.cambridge.org/us/dictionary/english/asian-pacificDate accessed: December 14, 2022Google Scholar Depending on the definition used, there are approximately 5 billion people who live in the region and make up most of the world population.2UNFPA Asia and the PacificPopulation Trends.https://asiapacific.unfpa.org/en/populationtrendsDate accessed: December 14, 2022Google Scholar In 2010, the Asia Pacific Heart Rhythm Society (APHRS) began collecting annual information on disease burden of arrhythmias and related clinical issues, availability of specialized therapies for arrhythmias, and workforce information from their member representatives and published the collated results in the APHRS White Book.3Asia Pacific Heart Rhythm SocietyThe APHRS White Book.https://www.aphrs.org/publications/the-aphrs-white-bookDate accessed: December 14, 2022Google Scholar Using these data and other sources, Figure 1 provides an estimate of the percentage of gross domestic product (GDP) used for healthcare for individual countries. There is a significant range for different countries in the region (from 2% to 10%).3Asia Pacific Heart Rhythm SocietyThe APHRS White Book.https://www.aphrs.org/publications/the-aphrs-white-bookDate accessed: December 14, 2022Google Scholar, 4Statista.http://www.statista.comDate accessed: December 14, 2022Google Scholar, 5Macrotrends.https://www.macrotrends.netDate accessed: December 14, 2022Google Scholar, 6The World BankWorld Bank Open Data.https://data.worldbank.orgDate accessed: December 14, 2022Google Scholar Use of nonpharmacologic therapies for arrhythmia care for different countries is shown in Figures 2 and 3. As shown in Figure 2, a wide range of cardiac implantable electronic device (CIED) implantation rates are observed, with the highest implant utilization in countries where a higher percentage of the GDP is directed to healthcare (Japan and New Zealand). The CIED implant rates in Japan and New Zealand are 598 per million and 720 per million, respectively. For comparison, one study from a rural county in the United States estimated that the CIED implant rate is 890 per million, and Germany has the highest reported CIED implant rate in Europe with an estimate of 1698 per million.7Vaidya V.R. Asirvatham R. Kowlgi G.N. et al.Trends in cardiovascular implantable electronic device insertion between 1988 and 2018 in Olmsted County.JACC Clin Electrophysiol. 2022; 8: 88-100Crossref PubMed Scopus (8) Google Scholar,8Raatikainen M.J.P. Arnar D.O. Merkely B. et al.A decade of information on the use of cardiac implantable electronic devices and interventional electrophysiological procedures in the European Society of Cardiology Countries: 2017 report from the European Heart Rhythm Association.Europace. 2017; 19: ii1-ii90Crossref PubMed Scopus (213) Google Scholar Low rates of CIED implantation are observed in countries where workforce issues are present. For example, in Pakistan and the Philippines, only a small percentage of the general population are physicians and, among physicians, only a very small percentage implant CIEDs Table 1. Use of ablation follows a similar pattern, with the highest ablation rates reported by Japan and New Zealand. While in most countries ablations for arrhythmias other than atrial fibrillation (AF) make up most ablation procedures, in Japan and South Korea a larger percentage of ablations are performed for the treatment of AF Figure 3.Figure 3Catheter ablation procedures (procedures per million) for different countries in the Asia Pacific region divided by atrial fibrillation (AF) ablation and non-AF ablation procedures for 2020 (∗Pakistan and Vietnam) and 2021.3Asia Pacific Heart Rhythm SocietyThe APHRS White Book.https://www.aphrs.org/publications/the-aphrs-white-bookDate accessed: December 14, 2022Google Scholar, 4Statista.http://www.statista.comDate accessed: December 14, 2022Google Scholar, 5Macrotrends.https://www.macrotrends.netDate accessed: December 14, 2022Google Scholar, 6The World BankWorld Bank Open Data.https://data.worldbank.orgDate accessed: December 14, 2022Google ScholarView Large Image Figure ViewerDownload Hi-res image Download (PPT)Table 1Percentage of physicians in the general population and percentage of physicians who implant pacemakers and perform ablationCountryPercentage of physicians in the general populationPercentage of physicians who implant pacemakersPercentage of physicians who perform ablationBrunei Darussalam0.15%0.75%0.15%CambodiaNANANAChina0.29%0.10%0.08%Hong Kong0.21%NANAIndia0.10%NA0.01%Indonesia0.08%0.05%0.01%Japan0.13%NA1.55%Malaysia0.00%3.69%1.38%Mongolia0.38%0.05%0.01%Myanmar0.01%5.41%3.35%New Zealand0.32%0.30%0.13%Pakistan0.04%0.02%0.00%Philippines0.12%0.04%0.00%Singapore0.28%0.16%0.13%South Korea0.25%0.09%0.08%Sri Lanka0.09%0.06%0.05%Taiwan0.22%1.81%0.11%Thailand0.06%NANAVietnam0.11%0.12%0.04%NA = not available. Open table in a new tab NA = not available. Brunei Darussalam is situated on the northwestern coast of Borneo in Southeast Asia and has a population of approximately 440,000 according to the 2021 census.9Department of Economic Planning and Statistics, Ministry of Finance and Economy, Brunei Darussalam. Population.https://deps.mofe.gov.bn/sitepages/population.aspxDate accessed: December 13, 2022Google Scholar Healthcare for citizens is largely free at the point of care, with permanent residents entitled to subsidized care. Other individuals rely on insurance or pay out of pocket. There are few published data on the prevalence of arrhythmias in Brunei Darussalam, but approximately 25.3% of stroke patients had AF, which is comparable to findings in a matched German population.10Bassa B. Güntürkün F. Craemer E.M. et al.Diabetes, hypertension, atrial fibrillation and subsequent stroke-shift towards young ages in Brunei Darussalam.Int J Environ Res Public Health. 2022; 19: 8455Crossref PubMed Scopus (1) Google Scholar In addition, other data suggest that survival from cardiac arrests remains very low (1.4%), with low rates of bystander cardiopulmonary resuscitation.11Johar S. Johani N.F. Cunningham A.C. Outcomes of cardiac arrest in Brunei Darussalam.J Asian Pac Soc Cardiol. 2022; 1: e21Crossref Google Scholar According to the 2022 APHRS White Book, 61 pacemakers, 18 cardiac resynchronization therapy (CRT) devices, and 27 implantable cardioverter defibrillators (ICDs) were implanted. A total of 102 ablation procedures were performed, mostly for AF, supraventricular tachycardia (SVT), and premature ventricular contractions.3Asia Pacific Heart Rhythm SocietyThe APHRS White Book.https://www.aphrs.org/publications/the-aphrs-white-bookDate accessed: December 14, 2022Google Scholar Lead extraction using powered tools is available, although numbers are low. A 3-dimensional mapping system is available for use, and the rates of conduction system pacing are increasing. On a per capita basis, the numbers of implanted devices and procedures performed indicate reasonable access to therapy. Cambodia is located in Southeast Asia with a total population of around 17 million.12WorldometerCambodia Population (Live).https://www.worldometers.info/world-population/cambodia-populationDate accessed: December 14, 2022Google Scholar The improvement in healthcare (both public and private sectors) has resulted in an of in accessed: December 14, 2022Google Scholar health is a in and remains as as the of Cambodia the to health insurance to in the country with the access to care procedures for life-threatening for the The of Cambodia health system for the Scholar disease is a major burden for the healthcare although heart in and rural A among the in that the of patients with arrhythmias AF, ventricular arrhythmia and presented with and at a with such as arrhythmia and cardiac In to countries, rheumatic heart disease is one of the of AF in and other physicians of with sudden cardiac such as and A total of with are located in one and management in arrhythmia care such as CIED implantation and ablation interventional procedures due to and In the be to and patients arrhythmias and other and to with national health insurance for the of interventional arrhythmia has a large population of around billion Population accessed: December 14, 2022Google Scholar the of healthcare providers and healthcare the has as as Population accessed: December 14, 2022Google Scholar cardiac to be the of in the of cardiac cardiac or with cardiovascular disease, are important The of is million per and are to and cardiac in A systematic Electrophysiol. 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