Relationship between atrial fibrillation ablation and gross domestic product across Europe

Atrial fibrillation (AF) is the most common sustained arrhythmia, and its prevalence is steadily increasing and expected to further increase, driven by population aging, cardiometabolic comorbidities, and improved detection.1–3 Atrial fibrillation is associated with substantial morbidity—including stroke, heart failure, and hospitalizations—and mortality, making effective management a public health priority.4,5 Over the past decade, the therapeutic landscape for AF has evolved: contemporary international guidelines emphasize early rhythm control strategies and, in appropriately selected patients, endorse AF catheter ablation (AF CA) as a first-line option to reduce AF burden and improve quality of life.4,5 Moreover, AF CA may also improve patients’ prognosis.4,5 Nevertheless, access to advanced rhythm control therapies remains uneven across world regions and even within European countries; population-based analyses and pan-European atlases document wide heterogeneity in electrophysiology (EP) capacity and AF CA availability, with socioeconomic and sex-related disparities in uptake.6,7 These differences in infrastructure and access may translate into variable patient pathways, costs, and outcomes; moreover, the direct and indirect economic burden of AF care is substantial, underscoring the relevance of system-level constraints.8 Against this backdrop, understanding how macrolevel factors—such as national economic context—relate to ablation use relative to overall AF prevalence is timely. In the present study, we therefore examine whether gross domestic product per capita (GDPpc) correlates with AF CA utilization after accounting for AF burden.1,2,4–8 Data on national populations and AF/atrial flutter (hereafter, AF) prevalence in European countries were obtained from the Global Burden of Disease (GBD) Study 2021, which reports incidence, mortality, and disability-adjusted life years (DALYs) for 371 diseases and injuries across 204 countries and territories from 1990 to 2021.9 In the GBD, AF is defined by the following: (i) irregularly irregular RR intervals; (ii) no distinct P waves on the surface ECG; and (iii) a variable atrial cycle length, typically ≤200 ms. Data on AF CA were taken from the 2025 European Society of Cardiology-European Heart Rhythm Association (ESC-EHRA) Atlas on heart rhythm disorders.6 Only European countries with available AF CA data were included. Atlas figures refer to procedures performed in 2022 or 2023. Data on GDPpc were retrieved from the World Bank.10 We calculated the prevalence of AF CA relative to the overall AF prevalence as annual AF CA procedures per 1000 prevalent AF cases (AF CA–AF ratio). We then assessed the correlation between the AF CA–AF ratio and GDPpc using Pearson’s correlation coefficient. All statistical analyses were conducted using R (version 4.4.1). We assembled country-level data for European countries, linking AF prevalence with AF CA activity and GDPpc. After excluding countries with missing variables, 35 countries were included. Atrial fibrillation catheter ablation activity ranged from 5.3 to 881 procedures per million inhabitants [median 228.6, interquartile range (IQR) 127.4–348.5] (Figure 1A), and when normalized to AF burden (i.e. AF CA–AF ratio), it spanned 0.48–63.20 (median 15.05, IQR 8.04–25.51) (Figure 1B). The lowest AF CA–AF ratios were observed in Bosnia and Herzegovina (0.48/1000), North Macedonia (1.27/1000), and Moldova (1.56/1000), whereas the highest in Switzerland (63.20/1000) and Belgium (61.96/1000); Belgium also had the highest AF CA rate per million (882/million). Median GDPpc was $32.6k (IQR $22.2–54.3k; range $6.8–131.4k). Gross domestic product per capita correlated positively with the AF CA–AF ratio (Pearson’s r = 0.595, 95% CI 0.33–0.77, P = 0.00016; R² = 35.4%) (Figure 1C). To enable cross-country comparison of ablation activity, choropleth heat maps were generated based on two complementary indicators: the number of AF CA procedures performed per 1 000 000 inhabitants in 2023 (A) and the number of AF CA procedures performed per 1000 patients with AF (B), reflecting population-level activity and procedural penetration within the AF population, respectively. For both metrics, values were stratified into five categories. (C) Pearson’s correlation between the AF CA–AF ratio and GDPpc. AF, atrial fibrillation; AF CA, atrial fibrillation catheter ablation; GDPpc, gross domestic product per capita. In this cross-sectional, ecological analysis restricted to European countries, we found a positive association between AF CA and GDPpc after accounting for AF burden, suggesting that economic factors influence the implementation of AF CA in the clinical arena. Current guidelines on AF advocate early rhythm control by AF CA for patients with paroxysmal AF and consider this procedure as an option for select patients with persistent AF.4,5 However, our analysis shows that implementation of these recommendations in clinical practice remains uneven across Europe, partly due to differences in regional economic backgrounds. Substantial scatter at comparable income levels indicates that GDP alone is not the only determinant of the disparity in AF CA use across European nations. Supply-side capacity, reimbursement frameworks, referral pathways, and adherence to guidelines also widely vary across Europe, as documented by ESC-EHRA atlases and surveys.6,7 Therefore, equalization of economic growth should not be viewed as the only way to promote a more homogeneous adoption of AF CA in Europe. Plausibly health system levers include expanding EP training positions and centres capacity, structuring reimbursement to cover index and redo procedures, and monitoring waiting times and regional coverage—especially for women and socioeconomically disadvantaged groups.6,7 We acknowledge that our analysis is explorative and has limitation, such as temporal misalignment and possible reporting bias of the AF, AF CA, and GDP datasets, use of country-level data instead of individual-level data, and the fact that AF CA was considered irrespective of the clinical indication according to which it had been performed. It should also be noted that GDPpc (nominal) is a coarse macroeconomic proxy; health expenditure per capita may better reflect health system capacity. The present analysis suggests that tracking AF CA–AF ratios provides a simple and interpretable indicator of procedural access, overcoming the limitations of crude ablation rates. This metric may capture disparities not only between but also within countries and could serve as a benchmarking tool across Europe.6 Atrial fibrillation catheter ablation utilization correlates strongly with national economic indicators, yet substantial residual variation suggests that system-level factors—organization, reimbursement, and workforce distribution—also influence access.4–8 Integrating both economic context and AF CA–AF ratios into future longitudinal and multivariable analyses could refine understanding of inequities and inform capacity planning. Embedding such indicators into health policy dashboards may guide resource allocation, promote equitable diffusion of evidence-based care, and support implementation of ESC recommendations across diverse economic and healthcare settings. Figure 1 was created with BioRender. None declared. All the data used fort this analysis are available on https://ghdx.healthdata.org/gbd-results-tool and among the supplementary data of the 2025 ESC-EHRA Atlas on heart rhythm disorders.