Does a patient with a right bundle branch block (RBBB) require referral to cardiology?

Management of Right Bundle Branch Block (RBBB)

Asymptomatic patients with isolated RBBB do not require referral to cardiology as this is typically a benign finding that does not warrant specific treatment. 1

Initial Assessment

• RBBB requires a comprehensive clinical evaluation to determine if the patient is symptomatic or asymptomatic 1
• A 12-lead ECG is necessary to confirm RBBB diagnosis and identify any additional conduction abnormalities 1
• Transthoracic echocardiography is reasonable in selected patients with RBBB if structural heart disease is suspected, but is not routinely required for all RBBB cases 2, 1

Risk Stratification

• Isolated RBBB with normal PR interval and 1:1 AV conduction in asymptomatic patients is generally benign and requires no specific intervention beyond routine follow-up 1
• Higher-risk features that may warrant cardiology referral include:
  • RBBB with left anterior or posterior fascicular block (bifascicular block) 1
  • RBBB with syncope or presyncope 2
  • RBBB with alternating bundle branch block (RBBB alternating with LBBB) 2
  • RBBB with structural heart disease 2, 1

Referral Recommendations

• Asymptomatic patients with isolated RBBB:

  • No cardiology referral needed 2, 1
  • No permanent pacing indicated 2
  • No specific restrictions on physical activity or competitive sports 2

• Patients requiring cardiology referral:

  • RBBB with syncope or presyncope (to evaluate for potential intermittent high-degree AV block) 2
  • RBBB with bifascicular block (increased risk of progression to complete heart block) 2, 1
  • RBBB with alternating bundle branch block (high risk of progression to complete AV block) 2
  • RBBB with evidence of structural heart disease 2, 1
  • RBBB in the context of suspected Brugada syndrome (persistent ST elevation in V1-V3) 2, 3

Advanced Evaluation (When Indicated)

• Ambulatory ECG monitoring is recommended for symptomatic patients with RBBB to detect potential intermittent AV block 2, 1
• Electrophysiology study (EPS) is reasonable in patients with syncope and RBBB to assess for HV interval prolongation or infranodal block 2
• Exercise testing may be useful if symptoms are exercise-related 1

Clinical Pearls and Pitfalls

• RBBB alone does not predict myocardial infarction in patients with chest pain, but is associated with increased mortality in ACS patients 4, 5
• Meta-analysis data suggests RBBB may be associated with increased mortality risk in the general population (HR: 1.17) and in patients with heart disease 6
• Unnecessary permanent pacing in asymptomatic patients with isolated RBBB is not indicated and may cause harm 1
• RBBB pattern during right ventricular pacing may indicate lead malposition or perforation and requires evaluation 7

Follow-up Recommendations

• Asymptomatic patients with isolated RBBB require no specific follow-up beyond routine care 2, 1
• Patients with RBBB and bifascicular block may benefit from periodic evaluation to assess for progression to higher-degree block 2
• Any development of symptoms (syncope, presyncope, exercise intolerance) in a patient with known RBBB should prompt reevaluation 2, 1