What is the treatment for Right Bundle Branch Block (RBBB)?

Treatment of Right Bundle Branch Block (RBBB)

Isolated asymptomatic Right Bundle Branch Block (RBBB) requires no specific treatment, as permanent pacing is not indicated for asymptomatic patients with isolated conduction disease and normal atrioventricular conduction. 1

Assessment and Management Algorithm

1. Determine if RBBB is Isolated or Associated with Other Conditions

• Isolated RBBB without symptoms:

  • No treatment required
  • Observation only
  • Permanent pacing is explicitly contraindicated (Class III: Harm) 1

• RBBB with specific high-risk features:

  • Alternating bundle branch block (RBBB alternating with LBBB): Permanent pacing recommended (Class I) 1
  • Syncope with HV interval ≥70 ms or infranodal block on electrophysiology study: Permanent pacing recommended (Class I) 1
  • RBBB with Kearns-Sayre syndrome: Permanent pacing reasonable, with additional defibrillator capability if appropriate (Class IIa) 1
  • RBBB with Anderson-Fabry disease and QRS >110 ms: Permanent pacing may be considered (Class IIb) 1

2. Management Based on Clinical Presentation

• RBBB with syncope:

  • Perform electrophysiology study to evaluate for HV interval prolongation or infranodal block
  • If EPS positive (HV ≥70 ms or infranodal block): Permanent pacing indicated 1
  • If EPS negative: Consider implantable loop recorder to detect intermittent AV block 1

• RBBB in acute coronary syndrome context:

  • New or presumably new RBBB in patients with symptoms suggestive of AMI: Assess for reperfusion therapy (Level C recommendation) 1
  • RBBB with concordant ST-segment deviations ≥0.1 mV towards major QRS deflection or discordant ST-segment deviations ≥0.5 mV away from major QRS deflection: Consider reperfusion therapy 1

Special Considerations

• RBBB with tachycardia:

  • If hemodynamically unstable: Immediate synchronized cardioversion 2
  • If stable: Obtain 12-lead ECG to determine mechanism (VT vs. SVT with aberrancy) 2
  • When diagnosis is uncertain, treat as ventricular tachycardia 2

• RBBB with heart failure:

  • Unlike LBBB, RBBB alone is not an indication for cardiac resynchronization therapy 1
  • Monitor for progression to more advanced conduction disorders

Long-term Monitoring

• RBBB without cardiovascular disease has been associated with increased risk of all-cause mortality and cardiovascular-related mortality in some studies 3
• Consider periodic cardiac evaluation, especially in patients with:
  • Hypertension (more common in RBBB patients)
  • Decreased exercise tolerance
  • Slower heart rate recovery after exercise 3

Pitfalls and Caveats

1. Do not implant pacemakers in asymptomatic patients with isolated RBBB - this is explicitly contraindicated and provides no benefit 1

2. Do not miss alternating bundle branch block - this rare condition indicates unstable conduction disease in both bundles and carries high risk of developing complete heart block 1

3. Do not assume all RBBB tachycardias are supraventricular - when diagnosis is uncertain, wide-complex tachycardias with RBBB morphology should be treated as ventricular tachycardia 2

4. Do not overlook underlying structural heart disease - RBBB may be a marker of early cardiovascular disease even in apparently healthy individuals 3

The management of RBBB should focus on identifying high-risk features that warrant intervention while avoiding unnecessary treatment in patients with isolated, asymptomatic RBBB.