In the majority of cases, right bundle branch block produces no symptoms of the heart condition. The more common sign and symptoms encountered in RBBB includes:
- Syncope or fainting
- Near-syncope or the feeling of about to faint
- Bradycardia or slow heart rate
- Chronic fatigue
Entire Body System
- Congestive Heart Failure
The incidence of angina pectoris, myocardial infarction, valvular heart disease, cardiomegaly, congestive heart failure, advanced heart block or cardiac death in these men did not differ from that of the control group over the observation period. [ncbi.nlm.nih.gov]
[…] on congestive heart failure. [interventional-cardiology.imedpub.com]
Abstract A 76 year old female, with medical history significant for systolic congestive heart failure, who presented to the emergency department with lethargy and abdominal pain with diarrhea for the past 3 weeks. [jbclinpharm.org]
Five days before, he was admitted to the emergency department for asthenia and was diagnosed with atrial fibrillation and secondary congestive heart failure. [bjcardio.co.uk]
Symptoms Fainting, near fainting, chronic fatigue, and palpitations are common symptoms of RBBB. Diagnosis Electrocardiography, echocardiography, and Holter monitoring may be necessary to diagnose the condition. [symptoma.com]
We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: May 13, 2019 [patientslikeme.com]
It can result in a clinical picture ranging from cardiogenic shock to general malaise, including dyspnoea, chest discomfort or fullness, peripheral oedema and fatiguability. [bjcardio.co.uk]
Case report A 72-year-old man was admitted to our hospital for asthenia and general malaise for a week. [bjcardio.co.uk]
We report the case of an 86-year-old man found at home with acute chest pain and dyspnea. He presented some episodes of left chest pain combined with dyspnea. [ncbi.nlm.nih.gov]
Finally, new right bundle branch block in patients experiencing dyspnea (particularly if acute) may indicate pulmonary embolism. [ecgwaves.com]
The patient had stable chronic dyspnea on exertion and has been on home oxygen therapy due to long-standing pulmonary emphysema. [innovationsincrm.com]
Ventricular conduction at baseline The patient reached a maximum load of 600 kgmts during exercise (6.14 mets, NYHA functional class: IIA), referring tired legs and limiting dyspnea. Table 1 summarizes clinical and EKG data during stress test. [medwave.cl]
Case report A 42 year old man with diabetes presented to accident and emergency with intermittent vomiting for three days. Over the previous two days he had been feeling increasingly tired, lethargic, polyuric, and thirsty. [ncbi.nlm.nih.gov]
- Heart Disease
Isolated right bundle branch block is generally regarded as a benign finding in the absence of underlying structural heart disease. [ncbi.nlm.nih.gov]
pulmonary embolism, rheumatic heart disease, myocarditis, cardiomyopathy, or hypertension. [en.wikipedia.org]
valvular heart disease or cardiomyopathy. [heart.bmj.com]
[…] conducting system (Lenegre disease) Hyperkalaemia Digoxin toxicity Ischaemic heart disease Rheumatic heart disease Right ventricular hypertrophy (cor pulmonale) Pulmonary embolus Cardiomyopathy Myocarditis Congenital heart disease (e.g. [medicalexamprep.co.uk]
- Heart Failure
[…] on congestive heart failure. [interventional-cardiology.imedpub.com]
We report the successful use of biventricular pacing in a patient with heart failure and a right bundle branch block conduction delay. [ncbi.nlm.nih.gov]
Talajic, et al., Resynchronization-Defibrillation for Ambulatory Heart Failure Trial Investigators, Cardiac-resynchronization therapy for mild-to-moderate heart failure, New England Journal of Medicine 363 (2010) 2385–2395. A. Puglisi, M. [e-coretvasa.cz]
We report a rare case of bundle branch reentrant ventricular tachycardia [BBRVT]. A 67-year-old female was admitted for management of wide QRS tachycardia (right bundle branch block [RBBB] and a southwest axis). [ncbi.nlm.nih.gov]
- Heart Block
None of the 14 patients with a pre-existing LBBB developed complete heart block. [journals.lww.com]
Free Education | October 1979 Right Bundle-branch Block and Complete Heart Block Caused by the Swan-Ganz Catheter Author Affiliations & Notes IAN R. THOMSON, M.D. * BRIAN C. DALTON, M.D. † DEMETRIOS G. [anesthesiology.pubs.asahq.org]
Trifascicular heart block is the combination of bifascicular block with first-degree heart block. [jadweb.org]
There are three main types of heart block: AV (atrioventricular) heart blocks Bundle branch blocks Tachybrady syndrome AV (atrioventricular) heart blocks An AV heart block happens when the electrical impulses are delayed or blocked as they travel between [bhf.org.uk]
Heart block, AV bundle, or bundle branch block affects the electrical system of the heart. It is different from coronary artery disease, which affects the heart’s blood vessels. [medicalnewstoday.com]
Although cardiac resynchronization therapy-defibrillator (CRT-D) was implanted in a heart failure patient with CRBBB, dyssynchrony worsened and stroke volume decreased, and this patient was re-admitted due to exacerbated heart failure. [ncbi.nlm.nih.gov]
Clinical cardiovascular disease at the baseline was defined by any of the following: a history of myocardial infarction, angina pectoris, heart failure, valvular heart disease, cardiomyopathy, and stroke. [kjim.org]
Connolly SJ, Kerr CR, Gent M et al (2000) Effects of physiologic pacing versus ventricular pacing on the risk of stroke and death due to cardiovascular causes. N Engl J Med 342:1385–1391 CrossRef PubMed Google Scholar 33. [doi.org]
Ventricular interdependence may result in impaired LV filling, a decrease in LV stroke volume, and low cardiac output. [ekjm.org]
Clinical Information, Serologic Testing, and Vital Status Age, gender, ethnicity, history of smoking, hypertension, coronary artery disease (CAD), previous stroke, SSc disease type (based on the extent of skin involvement), modified Rodnan Skin Score [journals.plos.org]
The following tests and diagnostic modalities are implored in the diagnosis of right bundle branch blocks:
- Electrocardiography (ECG): This makes use of multiple electrodes place on the chest of the patient to record the cardiac electrical activities. Often times, RBBB is an incidental ECG finding while another cardiac disease is being worked up.
- Echocardiogram: The use of a two dimensional echocardiograph can elucidate a detailed view of the cardiac structures. This can demonstrate the actual movement of the heart wall, muscles and valves. The discovery of an atrial septal defect (ASD) or ventricular septal defect (VSD) can be facilitated by the echocardiogram.
- Holter monitoring: A continuous ambulatory monitoring of the cardiac electrical activity may be indicated in post-operative cases who undergone VSD or tetralogy of Fallot cardiac repair .
- Wide QRS Complex
These are the criteria for multifocal atrial tachycardia MAT, also known as chaotic atrial rhythm,1 chaotic atrial tachycardia,2 and chaotic atrial mechanism.3 The wide QRS complexes ≥ 0.12 s with broad S waves in leads I, aVL, and the lateral precordial [ncbi.nlm.nih.gov]
The computer is measuring the QRS duration here at 132 ms (0.132 s) which is greater than 120 ms (0.12 s). So we have a supraventricular rhythm with wide QRS complexes. [ems12lead.com]
Right bundle branch block As illustrated in the electrocardiogram below, right bundle branch block presents with delayed activation of the right ventricle, leading to a wide QRS complex lasting greater than 0.12 seconds. [meds.queensu.ca]
- Prolonged PR Interval
The one patient with RBBB and prolonged PR interval died of a cardiac arrhythmia. [jamanetwork.com]
PR-interval, right axis deviation, (V1-3) [Figure 2]A, [Figure 2]B, [Figure 2]C. [jadweb.org]
The figure below gives an overview but we will look at each block in more detail. 1 st degree heart block 1st degree block indicates slowed transmission of electrical activity through the AV node – therefore giving a prolonged PR interval. [oxfordmedicaleducation.com]
The PR interval is prolonged beyond the normal upper limit of 0.21 seconds. The QRS and T waves are of normal morphology (shape and duration). [courses.kcumb.edu]
- Right Bundle Branch Block
[…] features and inclusion criteria of complete left or right bundle branch block Apply the process for measurement to determine the presence of left or right complete bundle branch block Analysis of ECGs People may choose to analyze ECG’s in a number of [ekg.academy]
[…] to the right bundle branch. Increased right intraventricular pressure, either acutely by pulmonary embolism or chronically as in cor pulmonale, can stretch the right bundle branch causing a bundle branch block. RBBB can also be induced iatrogenically [ncbi.nlm.nih.gov]
ECG (Example 1) Right Bundle Branch Block (RBBB) ECG (Example 2) Right Bundle Branch Block (RBBB) ECG (Example 3) Right Bundle Branch Block (RBBB) ECG (Example 4) Right Bundle Branch Block (RBBB) ECG (Example 5) Right Bundle Branch Block (RBBB) ECG (Example [healio.com]
- Incomplete Right Bundle Branch Block
He developed incomplete right bundle branch block during first stage of exercise and later on developed incomplete and complete right bundle branch block on alternate beats (2:1). [ncbi.nlm.nih.gov]
Right Bundle Branch Block (RBBB) ECG (Example 1) Incomplete Right Bundle Branch Block (RBBB) ECG (Example 2) Monomorphic Sustained Ventricular Tachycardia ECG (Example 3) Rate-Dependent Right Bundle Branch (RBBB) Block ECG Right Bundle Branch Block [healio.com]
In people with incomplete right bundle branch block the QRS complex duration by definition will be less than 120 msec. Incomplete right bundle branch block is common and usually a normal finding but may be associated with underlying pathology. [cardiologytoday.com.au]
- Complete Left Bundle Branch Block
There are several possible explanations for the intermittent shift in the QRS axis in the presence of complete left bundle branch block. [ncbi.nlm.nih.gov]
For any physician, the differentiation between complete right bundle-branch block (RBBB) and complete left bundle-branch block (LBBB) is almost as important as the differentiation between right-hand drive and left-hand drive for the general population [link.springer.com]
The more common alternating bundle branch block morphology is complete left bundle branch block alternating with normal ventricular conduction. [medwave.cl]
1 Quality: Estonian täielik Hisi kimbu vasaku sääre blokaad; English complete left bundle branch block; Last Update: 2014-11-21 Usage Frequency: 1 Quality: Estonian Hisi kimbu sääre blokaad Respiratoorsed, rindkere ja mediastiinumi häired: English Bundle [mymemory.translated.net]
Diagnostic criteria for right bundle branch block Diagnostic criteria for left bundle branch block Diagnostic Strict Criteria for left bundle branch block by Strauss QRS duration >0.12 s QRS duration of >0.12 s QRS duration ≥0.14s for men and ≥0.13s for [interventional-cardiology.imedpub.com]
- T Wave Inversion
Delayed activation of the right ventricle also gives rise to secondary repolarization abnormalities, with ST depression and T wave inversion in the right precordial leads. [lifeinthefastlane.com]
The ECG revealed new findings, including normal sinus rhythm, (RBBB), multiple ST segment abnormalities, S1Q3T3 pattern, and T wave inversion V1-V3. [journals.lww.com]
These included the documentation of sustained VT of the morphology described in Table 1 (arrhythmia criteria), the presence of epsilon waves (depolarization criteria) and T-wave inversions in [V.sub.1], [V.sub.2], and [V.sub.3] in the absence of complete [medical-dictionary.thefreedictionary.com]
- Wide S-wave in lateral leads ( Lead I, V5-6, aVL) - There will also be T wave inversion in the anterior leads - There may be an extra R wave in the anterior leads ( R'), or there may just be a broad slurred QRS. - The depolarization of the right ventricle [derangedphysiology.com]
- Myocardial Fibrosis
[…] appeared to be similarly involved, and the myocardial lesions had no relationship to coronary artery distribution (suggesting that the fibrosis was not related to a previous myocardial infarction) or to the presence of pulmonary, renal, or hypertensive [journals.plos.org]
It revealed as well the presence of extensive myocardial fibrosis detected by late gadolinium enhancement (figure 3). Figure 3. [escardio.org]
Hypertension predisposes to the development of bundle branch block, primarily by potentiating the development of generalized myocardial fibrosis, sclerosis of the left side of the cardiac skeleton or primary sclerodegenerative changes of the bundle branches [kjim.org]
Other ECG Findings
- Electrocardiogram Change
Electrocardiogram changes are common and precede the development of hypotension and neurological deterioration, therefore close watch on ECG monitoring is strongly recommended in the patients of TCAs poisoning. References 1. [mjdrdypu.org]
Patients presenting with asymptomatic heart block or a first degree heart block do not require any treatment. However, in RBBB presenting with an underlying condition, treatment may be necessary to control the disorder.
These may require the intake of medications to control hypertension or diabetes as the primary underlying cause. An invasive coronary angioplasty may be done to repair the blocked coronary arteries to relieve the impending RBBB.
In patients presenting with recurrent fainting, the implantation of an internal pacemaker may prevent further fainting spells. The pacemaker will generate regular electric impulses to regulate heart rhythm and ensure an optimal cardiac pumping.
Some forms of naturally occurring right bundle branch block like familial bundle branch block has a good prognostic outcome. Post VSD repair scarring of heart tissues may present eminently of electrophysiologic studies but may prove to be benign in the long run. However, cardiac scarring due to the tetralogy of Fallot repair have increases risk of cardiac arrhythmia and sudden cardiac death.
ECG finding of right bundle branch block associated with the Brugada syndrome , arrhythmogenic right ventricular cardiomyopathy (ARVC) , and Kearne-Sayre syndrome are also at high risk with sudden cardiac death and arrhythmia; thus, carry a grim prognosis in patients .
The following cardiac conditions are common complications associated with the right bundle branch block:
- Symptomatic bradycardia: The right bundle branch block may consequently slow down the rate of conduction and heart rate causing significant symptoms requiring pacemaker installation in most patients.
- Sudden cardiac death occurs when the bundle branch completely fails to transmit electrical impulses and results to cardiac arrest.
- Misdiagnosis of cardiac diseases: The ongoing RBBB may distort or complicate ECG readings of other heart disorders like myocardial infarction causing a delay in management and an increase in the mortality and morbidity rate in patients.
The following medical conditions can directly cause right bundle branch block in patients:
- Atrial septal defect
- Myocardial infarction
- Viral or bacterial myocarditis
- Scar tissue after heart surgery
- Pulmonary embolism
- Hereditary or familial bundle branch blocks 
- Family history of unexplained sudden cardiac death 
- Maternal human immunodeficiency virus (HIV) infections 
In the United States, the most common cause of right bundle branch block among children is post-surgical repair scarring of ventricular septal defect (VSD). The incidence rate for RBBB in the surgical repair of VSD alone is 25-81% and up to 60-100% after surgical cardiac repair in tetralogy of Fallot.
The long term effect of surgically induced RBBB in VSD repair has no major hemodynamic significance on the patient. However, in patients who underwent repair of the tetralogy of Fallot may consequently have QRS prolongation of up to 180 milliseconds and may carry some risk for arrhythmia and sudden cardiac death.
A number of trained athletes my present with complete and incomplete RBBB by voltage that points to an innocent physiologic cardiac remodeling phenomenon of the right atrium .
The basic pathophysiological defect in right bundle branch block is primarily due to the non-conduction of electrical impulses from the bundle of His to right bundle branch tracks.
In the advent that the left bundle branch conducts normally, right ventricular depolarization becomes significantly discordant with the left ventricle. This ventricular depolarization mismatch gives out the characteristic electrocardiograph (ECG) reading. There are rare cases of exercise induced right bundle branch block which are presenting similarly but are clinically benign .
Not all right bundle branch block conditions are preventable. However, RBBB can effectively be prevented by keeping the heart healthy to avert cardiac conditions that results to RBBB. The following useful tips can reduce the risk for coronary artery disease that can lead to RBBB:
- A regular healthy diet that is low on cholesterols and fats.
- Regular cardio exercise in up to 30 minutes minimum per week.
- Maintaining an ideal body weight.
- Quitting cigarette smoking.
- Control of hypertension with maintenance antihypertensive medications.
- Active control of diabetes.
- Prompt treatment of hypercholesterolemia and triclyceridemia.
- Regular follow-up with cardiologist for post-operative cardiac patients .
Right bundle branch block (RBBB) refers to a clinical condition wherein the transmission of impulses towards the right ventricle is significantly delayed. The blockage of the right sided electrical pathway can make it difficult for the heart to pump efficiently. There are no specific treatment for RBBB and all management is geared towards the resolution of the underlying cardiac disease.
Right bundle branch block (RBBB) is clinically defined as a significant delay in the transmission of electrical impulse from the AV node to the right bundle branch of the heart.
Atrial septal defect, myocardial infarction, recent cardiac surgery, infectious myocarditis, pulmonary embolism, and familial bundle branch block may lead to this disorder.
Fainting, near fainting, chronic fatigue, and palpitations are common symptoms of RBBB.
Electrocardiography, echocardiography, and Holter monitoring may be necessary to diagnose the condition.
Treatment and follow-up
Management of underlying cardiac cause and pacemaker installation are common treatment options.
- Stephan E, Chedid R, Loiselet J, Bouvagnet P. Clinical and molecular genetics of familial bundle branch block related to chromosome 19 [in French]. Arch Mal Coeur Vaiss. Dec 1998; 91(12):1465-74.
- Finnish Medical Society Duodecim. Myocardial infarction. In: EBM Guidelines. Evidence-Based Medicine. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2008 Apr 2.
- Diogenes MS, Succi RC, Machado DM, et al. Cardiac longitudinal study of children perinatally exposed to human immunodeficiency virus type 1 [in Portuguese]. Arq Bras Cardiol. Oct 2005; 85(4):233-40.
- Kim JH, Noseworthy PA, McCarty D, Yared K, Weiner R. Significance of electrocardiographic right bundle branch block in trained athletes. Am J Cardiol. 2011; 107(7):1083-9
- Stein R, Nguyen P, Abella J, Olson H, Myers J, Froelicher V. Prevalence and prognostic significance of exercise-induced right bundle branch block. Am J Cardiol. Mar 1 2010; 105(5):677-80.
- Deschenes I, Baroudi G, Berthet M, et al. Electrophysiological characterization of SCN5A mutations causing long QT (E1784K) and Brugada (R1512W and R1432G) syndromes. Cardiovasc Res. Apr 2000; 46(1):55-65.
- Marcus FI, McKenna WJ, Sherrill D, Basso C, Bauce B, Bluemke DA, et al. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the Task Force Criteria. Eur Heart J. Apr 2010; 31(7):806-14.
- van Beynum I, Morava E, Taher M, Rodenburg RJ, Karteszi J, Toth K, et al. Cardiac arrest in kearns-sayre syndrome. JIMD Rep. 2012; 2:7-10.
- Jain R, Dalal D, Daly A, et al. Electrocardiographic features of arrhythmogenic right ventricular dysplasia.Circulation. Aug 11 2009; 120(6):477-87.
- Hui W, Slorach C, Dragulescu A, Mertens L, Bijnens B, Friedberg MK. Mechanisms of Right Ventricular Electromechanical Dyssynchrony and Mechanical Inefficiency in Children After Repair of Tetralogy of Fallot.Circ Cardiovasc Imaging. May 1 2014