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Right Bundle Branch Block – Causes, Symptoms & Treatment

Right bundle branch block (RBBB) is a cardiac conduction disorder in which electrical impulses through the right bundle branch are delayed or blocked, typically detected on an ECG.

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Things worth knowing about "Right Bundle Branch Block"

Right bundle branch block (RBBB) is a cardiac conduction disorder in which electrical impulses through the right bundle branch are delayed or blocked, typically detected on an ECG.

What is Right Bundle Branch Block?

Right bundle branch block (RBBB) is a disorder of the electrical conduction system of the heart. Under normal conditions, the electrical impulse that triggers each heartbeat travels simultaneously down two conduction pathways – the left and right bundle branches – to activate both ventricles at the same time. In RBBB, conduction through the right bundle branch is slowed or completely interrupted, causing delayed activation of the right ventricle.

A distinction is made between complete RBBB (QRS duration on ECG ≥ 120 ms) and incomplete RBBB (QRS duration 100–119 ms). RBBB is not a disease in itself, but rather a finding on an electrocardiogram (ECG) that may point to various underlying conditions.

Causes

Right bundle branch block can occur in a variety of clinical contexts:

Idiopathic (no identifiable cause): An isolated RBBB without underlying heart disease is relatively common, especially in older individuals, and is often considered a benign incidental finding.
Heart disease: Coronary artery disease, myocardial infarction (especially anterior wall), myocarditis (inflammation of the heart muscle), cardiomyopathies, and congenital heart defects.
Lung conditions: Pulmonary embolism, chronic obstructive pulmonary disease (COPD), and pulmonary hypertension can cause right heart strain, which may lead to RBBB.
Cardiac surgery: Procedures involving the right ventricle or heart valves may result in RBBB.
Electrolyte disturbances and medications: Certain antiarrhythmic drugs and severe electrolyte imbalances can affect cardiac conduction.

Symptoms

In most cases, right bundle branch block causes no direct symptoms. Many people only learn about this finding incidentally during a routine check-up or ECG.

When symptoms do occur, they are typically related to the underlying heart condition and may include:

Palpitations or irregular heartbeat
Dizziness or lightheadedness
Shortness of breath, especially during physical exertion
Chest pain or pressure
In rare cases: fainting (syncope)

Diagnosis

The diagnosis of RBBB is made primarily through an electrocardiogram (ECG). Characteristic ECG findings include:

Widened QRS complex (≥ 120 ms in complete RBBB)
Characteristic rSR' pattern (M-shaped configuration) in leads V1 and V2
Broad S wave in the lateral leads I, aVL, V5, and V6

Additional tests may be needed to identify or rule out an underlying cardiac cause:

Echocardiography: Ultrasound examination of the heart to assess structure and function
Exercise stress test: Evaluation of cardiac function under physical load
Holter monitor (24–48 hour ECG): Continuous recording of heart rhythm
Blood tests: Such as troponin, BNP, or D-dimer in cases of suspected acute disease
Imaging: Cardiac MRI or CT in specific clinical scenarios

Treatment

Right bundle branch block itself generally requires no specific treatment, as it is an electrophysiological finding rather than a standalone disease.

Treatment is always directed at the underlying cause:

Coronary artery disease or myocardial infarction: Medical therapy, stent implantation, or bypass surgery
Pulmonary embolism: Anticoagulation or, in severe cases, thrombolytic therapy
Heart failure with bundle branch block: In selected patients, cardiac resynchronization therapy (CRT) with a specialized pacemaker may be beneficial
Myocarditis: Rest, anti-inflammatory treatment, and regular cardiological follow-up

Patients with an isolated, asymptomatic RBBB and no structural heart disease typically require only regular cardiological monitoring.

Prognosis

The prognosis of right bundle branch block depends largely on its underlying cause. An isolated RBBB without structural heart disease generally carries a favorable prognosis and does not significantly affect life expectancy. However, when RBBB occurs in the context of serious cardiac disease, the prognosis is primarily determined by the underlying condition.

References

Pérez Riera AR, Barbosa-Barros R, de Rezende Barbosa MP et al. - Right bundle branch block: an updated overview. Indian Pacing Electrophysiol J. 2020;20(5):219-228. PubMed PMID: 32682011.
Surawicz B, Childers R, Deal BJ et al. - AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. J Am Coll Cardiol. 2009;53(11):992-1002.
Lilly LS (ed.) - Pathophysiology of Heart Disease. 6th edition. Wolters Kluwer, 2016.

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