Modifiable predictors of atrioventricular block warranting a pacemaker: A cohort study
Anna-Sophie Thein, Janet J. Tang, Jean Jacques Noubiap, Thomas A. Dewland, Tor Biering-Sørensen, Gregory M. Marcus
Abstract
Recent studies focused on atrial fibrillation have demonstrated that the etiology of cardiac arrhythmias may be influenced by modifiable risk factors. It remains unknown if similar predictors are relevant to bradyarrhythmias, the most severe form being atrioventricular (AV) block warranting a pacemaker.
Introduction
Pacemakers have been essential in treating bradyarrhythmias for decades, and it is estimated that 1.25 million patients worldwide receive a permanent pacemaker every year [1]. The number of pacemaker implantations and the life span of pacing dependence are increasing [2,3] with the aging population.
Materials and methods
We conducted a longitudinal cohort study using the HCAI databases that capture every emergency department visit, inpatient hospitalization, and outpatient procedure in California, with the exception of Veterans Affairs and military facilities [18].
Results
The study included 28,640,453 patients (Fig 1). The mean age was 44.2 ± 19.3 years, 54% were female, and 0.3% received a pacemaker for AV block over a mean follow-up of 9.8 ± 4.8 years. Baseline characteristics are presented in Table 1.
Discussion
In a large cohort of patients who received care in an emergency department, hospital, or outpatient surgery facility in California, we found that older age, male sex, having a higher income, and having more cardiovascular comorbidities increased the risk of undergoing pacemaker implantation for AV block, whereas Asian and Pacific Islander and Black patients were at lower risk than White patients.
Conclusion
In this large longitudinal cohort study, we found that certain demographic characteristics, multiple established cardiovascular risk factors, and several common modifiable lifestyle factors predicted AV block warranting a pacemaker.
Citation: Thein A-S, Tang JJ, Noubiap JJ, Dewland TA, Biering-Sørensen T, Marcus GM (2026) Modifiable predictors of atrioventricular block warranting a pacemaker: A cohort study. PLoS One 21(9): e0356491. https://doi.org/10.1371/journal.pone.0356491
Editor: Ahmed Mustafa Rashid, Baylor Scott & White Research Institute, UNITED STATES OF AMERICA
Received: August 29, 2024; Accepted: August 3, 2026; Published: September 9, 2026
Copyright: © 2026 Thein et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The analytic methods (i.e. program code) are available in the supplemental material. Access to the dataset can be requested from the California Department of Health Care Access and Information (HCAI) by qualified researchers; https://hcai.ca.gov/data/request-data/.
Funding: Anna-Sophie Thein was funded by the Lundbeck Foundation on a scholarship (no grant number applicable). The Lundbeck Foundation had no role in the study design, data collection or analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
