Right bundle branch block differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]; Aarti Narayan, M.B.B.S [3]

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Differentiating Right bundle branch block from other Diseases

Right bundle branch block should be differentiated from the following;

The criteria to diagnose a left bundle branch block on an electrocardiogram includes the following:

  1. The heart rhythm must be supraventricular in origin. A wide QRS complex that is not preceded by P waves would not qualify.
  2. The QRS duration must be greater than or equal to 120 milliseconds.
  3. There should be a QS or rS complex in lead V1.
  4. There should be a monophasic R wave in lead I and lead V6.

The T wave deflection should be opposite of the terminal deflection of the QRS complex. This lack of concordance in direction is known as appropriate T wave discordance, and it is expected in patients with a left bundle branch block. A concordant T wave may suggest the presence of either ischemia ormyocardial infarction.

Type 1 Brugada pattern is characterized by ST elevations in leads V1-V3 with a right bundle branch block (RBBB) like pattern, although it is actually a cause of "pseudo right bundle branch block" as electrocardiographically right bundle branch block is not actually present. Aprolongation of the PR interval is also frequently seen.

Ventricular tachycardia and accelerated idioventricular rhythm can give rise to EKG patterns that mimic right bundle branch block. QRS complex will be wide and can have the appearance of a right bundle branch block, if the dominant rhythm originates from a pacemaker in the ventricle.

Biventricular pacing can result in QRS complexes that sometimes resemble RBBB. However the presence of pacemaker spikes at the beginning of the QRS complexes can differentiate a paced rhythm from a right bundle branch complex.

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