Nocturnal Atrioventricular Block: Natural History and Clinical Implications

BACKGROUND: Atrioventricular block (AVB) occurring exclusively at night has traditionally been considered a result of increased vagal tone and thought to have a favorable prognosis. While nocturnal AVB is generally not an indication for pacemaker implantation, supporting evidence remains limited. This study aimed to assess the natural history of nocturnal AVB. METHODS: Patients with 2:1, high-degree, or complete AVB (CAVB) detected exclusively during nighttime (21:00-07:00) on 24-hour electrocardiogram (ECG) monitoring were classified as having nocturnal AVB. The primary outcome was pacemaker implantation during the follow-up period. RESULTS: A total of 10,977 individuals underwent 24-hour ECG monitoring in Seoul St. Mary's Hospital between January 2000 and June 2020. Among them, 342 patients were diagnosed with CAVB, high-degree AVB, or 2:1 AVB, and 92 of these 342 patients had nocturnal AVB. Excluding 11 patients lost to follow-up, 81 patients were enrolled. Fourteen patients underwent immediate pacemaker implantation due to daytime bradycardia symptoms, while the remaining 67 patients underwent watchful waiting. During a median follow-up period of 2.4 years, 14 of these 67 patients received pacemaker implantation (n: CAVB 5/14, high-degree AVB 4/14, 2:1 AVB 5/14). The indications for pacemaker insertion included the development of bradycardia symptoms or signs (n = 13) and sick sinus syndrome (n = 1) during the daytime. CONCLUSION: Despite being asymptomatic during the daytime, 21% (14/67) of patients with nocturnal AVB required pacemaker implantation during a median follow-up period of 2.4 years. These findings suggest that active surveillance is needed even in patients with nocturnal AVB.