Robert Lemery MD
From the Arizona Heart Rhythm Center and St-Joseph’s Hospital, Dignity
Health, Phoenix, Arizona.
Address for correspondence: Rlemery@rogers.com
Word Count: 1,497
Within the last year at the Annual Scientific Sessions of the European
Heart Rhythm Association (EHRA) in Lisbon, of the Heart Rhythm Society
(HRS) in San Francisco, of the Asia Pacific Heart Rhythm Society (APHRS)
in Bangkok, as well as at other such organizations around the world, the
usual congratulatory celebrations for each organization were a propos.
As with most medical congresses, there is always true excitement for
members at being together, attending cutting edge presentations and
being introduced to new concepts given by emerging and known leaders in
the field of cardiac electrophysiology.
One year later, there is so much stupor and sadness with the current
pandemic that we are all trying to come to grips with the suddenness of
unfolding events that appear out of control. The health care workers
close to patients with SARS-CoV-2 have been overwhelmed by the difficult
working conditions and the high mortality of very sick patients
requiring hospital admission and transfer to intensive care units.
Whether now or later, many or most members of Heart Rhythm Societies
will be asked to evaluate patients suspected of having or having had
SARS-CoV-2. The pandemic kills with predilection older individuals, most
often with underlying cardiovascular diseases. Cardiac
electrophysiologists have followed many of those patients; like other
health care workers, they are also at risk of acquiring COVID-19.
The pandemic has not discriminated per se regions of the world, but as
often the case with global illnesses, the low and middle-income
countries (LMICs) could potentially suffer disproportionally (1, 2).
Under the best of times, economies in LMICs are fragile and require
ongoing subsidies and support from developed countries. The pandemic
amplifies greatly the hardship in LMICs. The collapse of economies in
developed countries without any warning, the effects of limiting
worldwide travel and assistance, and the immediate interruption of
channels of support all have the potential to result in significant
worsening health care from the pandemic in LMICs.
These countries are no longer afflicted by early mortality attributed to
high death rates from traditional infectious diseases (3). The Bill and
Melinda Gates Foundation founded in 2000, the Clinton and Bush
initiatives towards eradicating HIV, the impact of Paul Farmer at Global
Heath (4), and many other groups or non-governmental organizations have
significantly improved the lives of millions of people in LMICs. As
would be expected, those same individuals are now living longer lives
and, as in developed countries, acquire cardiovascular diseases
requiring ever more assistance and support in their communities.
In this era of globalization, there have been significant efforts to
assist populations in LMICs afflicted by rhythm disorders of the heart.
In 1984, NASPE (North American Society of Pacing and Electrophysiology),
the precursor organization to HRS, sponsored a two-day conference in
Washington D.C. on reuse of pacemakers (5). Predominantly to respond to
the growing costs of technological products in medicine, ultimately the
meeting attempted to resolve the legal, ethical and technological
dilemma of using refurbished pacemakers. The Food and Drugs
Administration provided 8 recommendations, including that refurbished
pacemakers could not be sold in the USA. The Europeans eventually
pursued the same approach (6), effectively eliminating reuse of
pacemakers in the Western world. However, channels to ship reused
devices to LIMCs had already been established, and the practice
continued and has even expanded by recent efforts of World Medical
Relief and HRS (7).
There are an estimated three million individuals who die yearly due to
heart block. The reuse of pacemakers and defibrillators for patients in
need in LMICs is not only perfectly understandable but also absolutely
needed to avoid the suffering and deaths of patients who cannot even
receive technology that was first made available in the West in the
1960’s. The country of Congo implanted their first pacemaker in 2014.
The INTER-CHF study recently reported on the growing trend for treating
heart failure in LMICs, and thus the increasing need for
cardiac-resynchronization therapies and defibrillators in those patients
(8)
When the tsunami caused by the 2020 pandemic recedes, and we find our
footing once again to schedule patients for elective ablation procedures
or device implantation, we must remember that millions of sick patients
with rhythm disorders and heart failure in LMICs will be left standing
without support. The cancelling of elective cases in developed countries
in anticipation of a surge of COVID-19 patients was not generally
detrimental to our patients. Yet this disturbing period in developed
countries, of waiting longer for scheduling cases, pales in comparison
to patients in LMICs that never have the opportunity to be scheduled at
all for a heart rhythm procedure.
While we continue to scramble to find old devices to reuse in patients
in need in LIMCs, there have been groups promoting unused or new devices
for those patients (9, 10). We need to advocate Industry to support
programs allowing teams to assist in the training of physicians in LMICs
to perform not only (unused) device implantation but also to establish
remote monitoring programs. The same reasoning applies to mapping and
ablation of tachyarrhythmias. Programs to support low-cost Direct Oral
Anticoagulants need to also be made available, to allow the World Health
Organization to add those drugs to the list of essential drugs in LMICs.
As a sub-specialty of cardiology, cardiac electrophysiologists have
mostly been insulated from the social causes of diseases. Our complex
and very technology-driven field has attracted basic scientists, health
care workers often specializing in technology and computing, as well as
physicians who find comfort being day in and day out in the
electrophysiology laboratory. More recently, as in other medical fields,
epidemiologists and statisticians, translational scientists and others
have brought the specialty of rhythm disorders to new heights.
Nonetheless, a large proportion of members of Heart Rhythm Societies are
clinicians, nurses and technologists who are extraordinary at providing
clinical care. That perceived weakness of all of these members being too
specialized to assist with those in need in LMICs is actually a
strength, by being able to provide specialized resources and
collaborating with organizations already in place, or by creating new
relationships to support governmental and health care centers in LMICs.
Our cherished HRS, preceded by NASPE, our European experts regrouping
under EHRA, the vast region of Asia-Pacific coming under APHRS, and all
other electrophysiological Societies, must now take the lead in
supporting major initiatives to support electrophysiological,
pharmacological and device therapies in LMICs. Over the last few years,
most of these organizations have included sessions on global health at
their annual scientific sessions. The great pandemic of 2020 has exposed
more than ever the global nature of health care and its disparities.
We must set new goals, far-reaching but entirely possible with the
support of the thousands of members of each of the Heart Rhythm
Societies. When we next meet at our Annual Scientific Sessions, we
should rejoice in being able to once again exchange about yet newer
technologies and progress in the field of rhythm disorders. But our
future Scientific Sessions should also be aspirational and a mandate to
make our wonderful medical specialty finally accessible to all.
References
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Eng J Med. 2020; Feb 28.
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8-year experience. Europace 2016; 18: 1038-1042