History

Fact Explanation
Chest pain [1] Patients with right bundle branch block (RBBB) can get myocardial ischemia/infarction in which the patient will present with chest pain [1] since the patients with RBBB and myocardial infarction often have significant coronary artery disease, they have a high mortality risk [6]
Gender-male [2] Studies have shown that the prevalence of RBBB is higher in men than women [2]
Old age [3] Studies have shown that the prevalence of RBBB is high in old age [8]
History of high blood pressure [1] Studies have shown that the prevalence of RBBB is high in patients who have high systolic blood pressure [1]
History of diabetes [1] Studies have shown that the prevalence of RBBB increases with diabetes.The exact cause for this is not known [1]
Patients with lung diseases/ chronic obstructive airway disease [3] RBBB may be a result of any lung condition that causes a chronic elevation in the pressures of the right ventricle [1]
Palpitations [4] Patients with RBBB can get arrhythmia which the patient feel as palpitations (less chance than the patients with left bundle branch block) [4] RBBB might be observed among idiopathic VF (ventricular fibrilation) patients and the prevalence of RBBB is higher in idiopathic VF patients than expected in the general population [7]
Fainting attacks [4] RBBB can give rise to heart blocks due to conduction abnormalities [4] It can also cause ventricular fibrilation leading to cardiac arrest [5]
Ankle swelling,shortness of breath when lying down [3] Patients with right ventricular cardiomyopathy and complete right bundle branch block very often have recurrent ventricular tachycardia and develop biventricular heart failure [8]
History of heart surgery [1] Damaging to conductive system of the heart is a potential risk factor during heart surgery as the right bundle branch, courses within the muscle of the right ventricle, in a relatively superficial manner [1]
History of structural heart defects [1] RBBB often occurs in any condition that affects the right ventricle eg: ventricular septal defects [1]
References
  1. BUSSINK B. E., HOLST A. G., JESPERSEN L., DECKERS J. W., JENSEN G. B., PRESCOTT E.. Right bundle branch block: prevalence, risk factors, and outcome in the general population: results from the Copenhagen City Heart Study. European Heart Journal [online] December, 34(2):138-146 [viewed 02 July 2014] Available from: doi:10.1093/eurheartj/ehs291
  2. ERIKSSON P.. Bundle-branch block in middle-aged men: risk of complications and death over 28 years: The Primary Prevention Study in Goteborg, Sweden. European Heart Journal [online] 2005 September, 26(21):2300-2306 [viewed 02 July 2014] Available from: doi:10.1093/eurheartj/ehi580
  3. FLEG JEROME L., DAS DHIRENDRA N., LAKATTA EDWARD G.. Right bundle branch block: Long-Term prognosis in apparently healthy men. Journal of the American College of Cardiology [online] 1983 March, 1(3):887-892 [viewed 02 July 2014] Available from: doi:10.1016/S0735-1097(83)80204-6
  4. VAN HEMEL N. M.. Left is worse than right: the outcome of bundle branch block in middle-aged men. European Heart Journal [online] 2005 September, 26(21):2222-2223 [viewed 02 July 2014] Available from: doi:10.1093/eurheartj/ehi390
  5. MANITA M, NAKAJIMA T, KANEKO Y, KURABAYASHI M. Idiopathic ventricular fibrillation associated with complete right bundle branch block? Intern Med [online] 2014, 53(6):633-4 [viewed 16 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24633037
  6. SøRENSEN JT, STENGAARD C, SøRENSEN CA, THYGESEN K, BøTKER HE, THUESEN L, TERKELSEN CJ. Diagnosis and outcome in a prehospital cohort of patients with bundle branch block and suspected acute myocardial infarction. Eur Heart J Acute Cardiovasc Care [online] 2013 Jun, 2(2):176-81 [viewed 16 September 2014] Available from: doi:10.1177/2048872613483591
  7. AIZAWA Y, TAKATSUKI S, SANO M, KIMURA T, NISHIYAMA N, FUKUMOTO K, TANIMOTO Y, TANIMOTO K, MURATA M, KOMATSU T, MITAMURA H, OGAWA S, FUNAZAKI T, SATO M, AIZAWA Y, FUKUDA K. Brugada syndrome behind complete right bundle-branch block. Circulation [online] 2013 Sep 3, 128(10):1048-54 [viewed 16 September 2014] Available from: doi:10.1161/CIRCULATIONAHA.113.003472
  8. PETERS S. QRS fragmentation in patients with arrhythmogenic right ventricular cardiomyopathy and complete right bundle branch block: a risk stratification. Eur Heart J Acute Cardiovasc Care [online] 2012 Sep, 1(3):236-9 [viewed 16 September 2014] Available from: doi:10.1177/2048872612453922

Examination

Fact Explanation
High blood pressure [1] Studies have shown that the prevalence of RBBB is high in patients who have high systolic blood pressure. Also patients can present with myocardial ischemia/infarction which can give rise to high blood pressure [1]
Pulse- bradycardia or tachycardia [2] Bradycardia due to heart blocks or tachycardia due to arrhythmia caused by defects in the conduction system of heart [2]
Barrel shape chest [3] RBBB may be a result of any lung condition that causes a chronic elevation in the pressures of the right ventricle [1]
Diabetic skin changes (loss of body hair,callosities etc) , diabetic retinopathic changes [1] Studies have shown that the prevalence of RBBB increases with diabetes.The exact cause for this is not known [1]
Ankle oedema [3] Congestive heart failure may occur in patients with RBBB due to ventricular dysfunction (less chance than in left bundle branch block) [3]
Scar marks of previous heart surgery [1] Damaging to conductive system of the heart is a potential risk factor during heart surgery as the right bundle branch, courses within the muscle of the right ventricle, in a relatively superficial manner [1]
References
  1. BUSSINK B. E., HOLST A. G., JESPERSEN L., DECKERS J. W., JENSEN G. B., PRESCOTT E.. Right bundle branch block: prevalence, risk factors, and outcome in the general population: results from the Copenhagen City Heart Study. European Heart Journal [online] December, 34(2):138-146 [viewed 02 July 2014] Available from: doi:10.1093/eurheartj/ehs291
  2. VAN HEMEL N. M.. Left is worse than right: the outcome of bundle branch block in middle-aged men. European Heart Journal [online] 2005 September, 26(21):2222-2223 [viewed 02 July 2014] Available from: doi:10.1093/eurheartj/ehi390
  3. FLEG JEROME L., DAS DHIRENDRA N., LAKATTA EDWARD G.. Right bundle branch block: Long-Term prognosis in apparently healthy men. Journal of the American College of Cardiology [online] 1983 March, 1(3):887-892 [viewed 02 July 2014] Available from: doi:10.1016/S0735-1097(83)80204-6

Differential Diagnoses

Fact Explanation
Left bundle branch block (LBBB) [1] Electrocardiogram- 1) QRS duration greater than or equal to 120 ms in adults, greater than 100 ms in children 4 to 16 years of age, and greater than 90 ms in children less than 4 years of age. 2) Broad notched or slurred R wave in leads I, aVL, V5, and V6 and an occasional RS pattern in V5 and V6 attributed to displaced transition of QRS complex. 3) Absent q waves in leads I, V5, and V6, but in the lead aVL, a narrow q wave may be present in the absence of myocardial pathology. 4) R peak time greater than 60 ms in leads V5 and V6 but normal in leads V1, V2, and V3, when small initial r waves can be discerned in the above leads. 5) ST and T waves usually opposite in direction to QRS. 6) Positive T wave in leads with upright QRS may be normal (positive concordance). 7) Depressed ST segment and/or negative T wave in leads with negative QRS (negative concordance) are abnormal [1]
References
  1. SURAWICZ BORYS, CHILDERS RORY, DEAL BARBARA J., GETTES LEONARD S.. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. Journal of the American College of Cardiology [online] 2009 March, 53(11):976-981 [viewed 02 July 2014] Available from: doi:10.1016/j.jacc.2008.12.013

Investigations - for Diagnosis

Fact Explanation
Electrocardiogram [1] Complete RBBB 1) QRS duration greater than or equal to 120 ms in adults, greater than 100 ms in children ages 4 to 16 years, and greater than 90 ms in children less than 4 years of age. 2) RSR in leads V1 or V2. The R deflection is usually wider than the initial R wave. In a minority of patients, a wide and often notched R wave pattern may be seen in lead V1 and/or V2. 3) S wave of greater duration than R wave or greater than 40 ms in leads I and V6 in adults. 4) Normal R peak time in leads V5 and V6 but greater than 50 ms in lead V1. Of the above criteria, the first 3 should be present to make the diagnosis. When a pure dominant R wave with or without a notch is present in V1, criterion 4 should be satisfied [1]
References
  1. SURAWICZ BORYS, CHILDERS RORY, DEAL BARBARA J., GETTES LEONARD S.. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. Journal of the American College of Cardiology [online] 2009 March, 53(11):976-981 [viewed 02 July 2014] Available from: doi:10.1016/j.jacc.2008.12.013

Investigations - Fitness for Management

Fact Explanation
Lipid profile [1] To control other co morbid conditions as patients with right bundle branch block have a high chance of mortality due to cardiovascular risk factors. Recommended low-density lipoprotein cholesterol target level in people with heart disease <100 mg/dl [1]
Fasting blood sugar [1] The prevalence of RBBB increases with diabetes [2] Also to control other co morbid conditions as patients with right bundle branch block have a high chance of mortality due to cardiovascular risk factors.Normal level <126mg/dl [1]
References
  1. ROTMAN M., TRIEBWASSER J. H.. A clinical and follow-up study of right and left bundle branch block. Circulation [online] 1975 March, 51(3):477-484 [viewed 02 July 2014] Available from: doi:10.1161/​01.CIR.51.3.477
  2. BUSSINK B. E., HOLST A. G., JESPERSEN L., DECKERS J. W., JENSEN G. B., PRESCOTT E.. Right bundle branch block: prevalence, risk factors, and outcome in the general population: results from the Copenhagen City Heart Study. European Heart Journal [online] December, 34(2):138-146 [viewed 02 July 2014] Available from: doi:10.1093/eurheartj/ehs291

Investigations - Followup

Fact Explanation
Echocardiogram [1] As the patients with rigt bundle branch block can go into heart failure,echocardiogram is done to check the ejection fraction, left ventricular dysfunction [1]
Electrocardiogram [2] To detect arrhythmia and heart blocks [2]
Lipid profile [3] To control other co morbid conditions as patients with right bundle branch block have a high chance of mortality due to cardiovascular risk factors. Recommended low-density lipoprotein cholesterol target level in people with heart disease <100 mg/dl [3]
Fasting blood sugar levels [3] The prevalence of RBBB increases with diabetes [4] Also to control other co morbid conditions as patients with right bundle branch block have a high chance of mortality due to cardiovascular risk factors.Normal level <126mg/dl [3]
References
  1. FLEG JEROME L., DAS DHIRENDRA N., LAKATTA EDWARD G.. Right bundle branch block: Long-Term prognosis in apparently healthy men. Journal of the American College of Cardiology [online] 1983 March, 1(3):887-892 [viewed 02 July 2014] Available from: doi:10.1016/S0735-1097(83)80204-6
  2. VAN HEMEL N. M.. Left is worse than right: the outcome of bundle branch block in middle-aged men. European Heart Journal [online] 2005 September, 26(21):2222-2223 [viewed 02 July 2014] Available from: doi:10.1093/eurheartj/ehi390
  3. ROTMAN M., TRIEBWASSER J. H.. A clinical and follow-up study of right and left bundle branch block. Circulation [online] 1975 March, 51(3):477-484 [viewed 02 July 2014] Available from: doi:10.1161/​01.CIR.51.3.477
  4. BUSSINK B. E., HOLST A. G., JESPERSEN L., DECKERS J. W., JENSEN G. B., PRESCOTT E.. Right bundle branch block: prevalence, risk factors, and outcome in the general population: results from the Copenhagen City Heart Study. European Heart Journal [online] December, 34(2):138-146 [viewed 02 July 2014] Available from: doi:10.1093/eurheartj/ehs291

Investigations - Screening/Staging

Fact Explanation
Electrocardiogram [1] Complete right bundle branch block (RBBB) 1) QRS duration greater than or equal to 120 ms in adults, greater than 100 ms in children ages 4 to 16 years, and greater than 90 ms in children less than 4 years of age. 2) RSR in leads V1 or V2. The R deflection is usually wider than the initial R wave. In a minority of patients, a wide and often notched R wave pattern may be seen in lead V1 and/or V2. 3) S wave of greater duration than R wave or greater than 40 ms in leads I and V6 in adults. 4) Normal R peak time in leads V5 and V6 but greater than 50 ms in lead V1. Of the above criteria, the first 3 should be present to make the diagnosis. When a pure dominant R wave with or without a notch is present in V1, criterion 4 should be satisfied [1] Also to detect arrhythmia and heart blocks [2]
Echocardiogram [3] Screen for structural heart lesions (eg:ventricular septal defects) as RBBB often occurs in any condition that affects the right ventricle. Also, as the patients with right bundle branch block can go into heart failure,echocardiogram is done to check the ejection fraction, left ventricular dysfunction [3]
Troponin I [3] Elevated Troponin I levels due to myocardial infarction [3]
References
  1. SURAWICZ BORYS, CHILDERS RORY, DEAL BARBARA J., GETTES LEONARD S.. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. Journal of the American College of Cardiology [online] 2009 March, 53(11):976-981 [viewed 02 July 2014] Available from: doi:10.1016/j.jacc.2008.12.013
  2. VAN HEMEL N. M.. Left is worse than right: the outcome of bundle branch block in middle-aged men. European Heart Journal [online] 2005 September, 26(21):2222-2223 [viewed 02 July 2014] Available from: doi:10.1093/eurheartj/ehi390
  3. FLEG JEROME L., DAS DHIRENDRA N., LAKATTA EDWARD G.. Right bundle branch block: Long-Term prognosis in apparently healthy men. Journal of the American College of Cardiology [online] 1983 March, 1(3):887-892 [viewed 02 July 2014] Available from: doi:10.1016/S0735-1097(83)80204-6

Management - General Measures

Fact Explanation
Dietary modifications [1] Since patients have high risk of cardiovascular mortality,diet control is necessary.Diet low in cholesterol [1]
Exercise [1] Has shown to improve cardiovascular well being [1]
Control of other co morbid conditions [1] Control diabetes ,hypertension and cholesterol levels as the patients with right bundle branch block has a high mortality due to cardiovascular events [2]
References
  1. ROTMAN M., TRIEBWASSER J. H.. A clinical and follow-up study of right and left bundle branch block. Circulation [online] 1975 March, 51(3):477-484 [viewed 02 July 2014] Available from: doi:10.1161/​01.CIR.51.3.477
  2. FLEG JEROME L., DAS DHIRENDRA N., LAKATTA EDWARD G.. Right bundle branch block: Long-Term prognosis in apparently healthy men. Journal of the American College of Cardiology [online] 1983 March, 1(3):887-892 [viewed 02 July 2014] Available from: doi:10.1016/S0735-1097(83)80204-6

Management - Specific Treatments

Fact Explanation
Percutaneous coronary intervension (PCI) [1] Acute myocardial infarction with right bundle branch block (RBBB) is frequently caused by the complete occlusion of the infarct-related artery and is more frequently treated with primary PCI [1]
Pacemaker [2] Required if a heart block is present [2]
Surgical correction of structural heart lesions [3] Correction of ventricular septal defects as RBBB often occurs in any condition that affects the right ventricle [3]
References
  1. WIDIMSKY P., ROHAC F., STASEK J., KALA P., ROKYTA R., KUZMANOV B., JAKL M., POLOCZEK M., KANOVSKY J., BERNAT I., HLINOMAZ O., BELOHLAVEK J., KRAL A., MRAZEK V., GRIGOROV V., DJAMBAZOV S., PETR R., KNOT J., BILKOVA D., FISCHEROVA M., VONDRAK K., MALY M., LORENCOVA A.. Primary angioplasty in acute myocardial infarction with right bundle branch block: should new onset right bundle branch block be added to future guidelines as an indication for reperfusion therapy?. European Heart Journal [online] December, 33(1):86-95 [viewed 02 July 2014] Available from: doi:10.1093/eurheartj/ehr291
  2. FLEG JEROME L., DAS DHIRENDRA N., LAKATTA EDWARD G.. Right bundle branch block: Long-Term prognosis in apparently healthy men. Journal of the American College of Cardiology [online] 1983 March, 1(3):887-892 [viewed 02 July 2014] Available from: doi:10.1016/S0735-1097(83)80204-6
  3. BUSSINK B. E., HOLST A. G., JESPERSEN L., DECKERS J. W., JENSEN G. B., PRESCOTT E.. Right bundle branch block: prevalence, risk factors, and outcome in the general population: results from the Copenhagen City Heart Study. European Heart Journal [online] December, 34(2):138-146 [viewed 02 July 2014] Available from: doi:10.1093/eurheartj/ehs291