Right bundle branch block natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Aarti Narayan, M.B.B.S [3]; Raviteja Guddeti, M.B.B.S. [4]

Natural History

Right bundle branch block may progress to complete heart block and sudden death if it is accompanied by higher grades of injuries to the conduction system, like first degree AV block and injury to the His-Purkinje system leading to a left anterior hemiblock.

In general, the natural history of right bundle branch block is benign. If right bundle branch block is due to surgery then there are generally no acute hemodynamic consequences. The subsequent courses also quite benign. An exception is if there is substantial injury to the His-Purkinje system in which case left anterior hemiblock or first-degree AV block may be present.

There are familial cases of right bundle branch block, which are benign.

Complications

Complication rate is higher in patients who have myocardial infarction and develop a new RBBB compared to those who have heart attack and not develop a new RBBB.

• Ventricular arrhythmias
• Sudden cardiac death
• RBBB can delay the accurate diagnosis of heart attack

Prognosis

• Isolated right bundle branch block without underlying heart disease has an excellent prognosis.
• In the presence of a known underlying heart disease, especially coronary artery disease, complete RBBB is associated with increased mortality.
• RBBB in the setting of acute myocardial infarction is associated with increased mortality even after the initiation of thrombolytic therapy.
• Studies have shown that RBBB is associated with worse outcomes in the long run in patients with established heart failure.
• Patients who have type II second degree atrioventricular block or multi-fascicular block along with RBBB have a poor prognosis compared to those without RBBB and such patients are also known to have a more significant myocardial disease.
• The Copenhagen City Heart Study showed that RBBB is associated with a significant increase in all-cause and cardiovascular mortality in both genders.
• There are three scenarios in which right bundle branch block can be associated with poor prognosis:

1. Brugada syndrome: If right bundle branch block is present, then sudden death may occur.
2. Kearns Sayre syndrome: Again, if right bundle branch block is present then sudden death may occur.
3. Tetralogy of Fallot: If right bundle branch block is present with a markedly prolonged QRS (> 180 ms), then the patient may be at risk for ventricular arrhythmias and sudden death.
4. Arrhythmogenic right ventricular cardiomyopathy: Risk of sudden death is higher.

• In children, surgically induced RBBB has a benign course in the long run, however rarely if RBBB is associated with injury to the His-Purkinje system, it is associated with progression to complete heart block and sudden death. Children who have undergone surgery for repair of tetralogy of Fallot are at increased risk for ventricular arrhythmias and sudden death.