Inequities in access to life-saving cardiac devices for heart failure: a comparative analysis of Chile and Mexico

BACKGROUND: Heart failure (HF) remains a leading cause of death in Latin America, yet access to cardiac implantable electronic devices (CIEDs) is limited. Chile provides HF treatment through the AUGE/GES (Universal Access with Explicit Guarantees in Health) program, while Mexico's public sector lacks such mechanisms for people without health insurance. This study aims to identify demographic and clinical factors associated with not receiving ICD or CRT-D among HF patients in Chile and Mexico. METHODS: This secondary analysis of the PLASMA study included 246 HF patients eligible for implantable cardioverter-defibrillators (ICDs) or cardiac resynchronization therapy with defibrillator (CRT-D) based on the 2017 ACC/AHA/HRS criteria. Variables included sociodemographic and clinical factors. We performed the Chi-square test and multivariable logistic regression analysis. RESULTS: Out of 246 eligible patients, 41.1% (n = 101) received ICD or CRT-D. The mean age of non-recipients was 64.1 years, compared to 58.5 years for recipients. Device implantation rates were higher in Chile (56%) than in Mexico (21%). Compared to Chile, Mexico had more recipients with NYHA class I (11.4% vs. 50%), even though the 2017 ACC/AHA/HRS criteria recommend ICDs and CRT-Ds mainly for symptomatic NYHA II-III patients, with stricter criteria for NYHA I (such as Left Bundle Branch Block, ≥ 40 days post-myocardial infarction, or QRS ≥ 150 ms with optimal therapy). Notably, Mexican patients had 7.6 times higher odds of not receiving a device compared to Chilean patients (aOR 7.58, 95%CI: 3.21-17.91). Care in public hospitals, older age, and NYHA III-IV were also associated with higher odds of not receiving a device, while ventricular arrhythmia and prior revascularization were associated with a lower likelihood of non-implantation (aOR 0.09, 95%CI: 0.04-0.18, and aOR 0.57, 95%CI: 0.33-0.99, respectively), indicating that these patients were substantially more likely to receive a device. No significant sex-related differences were observed. CONCLUSIONS: There are substantial inequities in access to life-saving cardiac devices between Chile and Mexico: structural and demographic factors, particularly the supply capacity of public hospitals and older age, significantly limit access.