Learn more about this abnormal ECG pattern

By Richard N. Fogoros, MD 

 Medically reviewed by Anisha Shah, MD

Bundle branch block is a heart conduction disorder caused by a disruption of one or both bundles of nerves that electrically stimulate the heart muscle—the left bundle branch and the right bundle branch—leading to an abnormal heart rhythm.¹ Typically, neither a left bundle branch block nor a right bundle branch block causes noticeable symptoms, with the exception of fainting in rare cases. Such blocks sometimes are due to underlying cardiac disease.²

Abnormal heart rhythm caused by bundle branch block can be diagnosed with an electrocardiogram (ECG) or echocardiogram. Treatment of the disorder may be unnecessary, but in severe cases a pacemaker and/or management of underlying heart disease may be required.

The Heart's Electrical System

The heart has four chambers that pump rhythmically by sequentially contracting and relaxing to circulate blood throughout the body and the lungs. Heart muscles are controlled by the cardiac electrical system, which is a branched distribution of nerves embedded in the heart muscle.

The sinus node is a bundle of nerves located in the right atrium. It controls the heart's electrical system by sending signals across the heart's left and right atria, stimulating them to contract. The message also passes through the atrioventricular (AV) node to the ventricles via a band of cardiac nerve fibers called the bundle of His.

The right and left bundle branches distribute the electrical impulse from the bundle of His across the right and left ventricles, causing them to beat. When the bundle branches are functioning normally, the right and left ventricles contract regularly and nearly simultaneously. This is described as normal sinus rhythm.

Types of Bundle Branch Block

If you have a bundle branch block, either the left bundle branch or the right bundle branch (or both) isn't functioning as it should. This leads to a disruption of heart rhythm as it pumps.

Note that while the term bundle branch “block” is used, the affected bundle branch may or may not be fully “blocked.” In many cases, the bundle branch is not completely blocked, but instead is simply conducting the electrical impulse more slowly than normal.

The chief effect of a bundle branch block is that it interferes with the coordinated contraction of the left and right ventricles. The contraction of one ventricle—the one that has a "blocked" bundle branch—occurs slightly after the contraction of the other, rather than at the same time.

Left Bundle Branch Block

The left side of the heart receives oxygenated blood into the left atrium from the lungs. This blood flows from the left atrium into the left ventricle, which contracts powerfully, sending oxygenated blood to the body.

A left bundle branch block interferes with the contraction of the left ventricle.

Right Bundle Branch Block

The right side of the heart receives deoxygenated blood from the body's circulation into the right atrium and sends this blood to the right ventricle, and then to the lungs to be replenished with oxygen.

The contraction of the right ventricle is normally slightly less powerful than the contraction of the left ventricle. A right bundle branch block disrupts the contraction of the right ventricle.

Symptoms 

In most cases, bundle branch block does not produce symptoms, so you might not know that you have this problem unless you have cardiac tests. However, it can cause intermittent effects, including dizziness and even syncope (fainting).

Such symptoms are more likely to occur if the bundle branch block exists along with a cardiovascular disease such as hypertension (high blood pressure), heart failure, or cardiomyopathy (disease of the heart muscle).³

Symptoms are also more common if the bundle branch block is severe or involves both the right and left bundle branches.

Possible effects of a bundle branch block:

• Overall, bundle branch block slightly increases the risk of health problems, including a decline in heart function.⁴

• Having a bundle branch block may increase the risk of a bad outcome if you are hospitalized for a heart condition.⁵

• Sometimes bundle branch block can pose a risk if you are having heart surgery for another cardiac problem, so it's important for your healthcare providers to know if you have this condition.⁶

With a very severe bundle branch block, the electrical impulse may suddenly stop reaching the ventricles altogether, leading to a complete heart block—which can produce syncope or sudden cardiac death. 

Causes and Risk Factors

Certain factors can increase the chances of bundle branch block, but the condition can occur without an identifiable cause, especially on the right side. Typically, when there is not an identifiable cause, the health effects of the bundle branch block are less significant and might even be completely negligible.

However, bundle branch block may be caused by underlying heart disease. In fact, left bundle branch block is almost always associated with a cardiac condition of some type.

The most common cardiac conditions associated with bundle branch block include:³ 

• Myocardial infarction (heart attack)

• Coronary artery disease (CAD)

• Myocarditis (inflammatory disease of the heart)

• Dilated cardiomyopathy

• Hypertrophic cardiomyopathy

• Heart valve disease

• A septal defect (usually congenital, from birth)

• Severe and prolonged hypertension

Right bundle branch block can develop due to all of these causes, and it can also occur as a result of a lung disease, including:

• Pulmonary embolus

• Chronic obstructive pulmonary disease (COPD)

• Pulmonary hypertension

Diagnosis

Identifying a bundle branch block relies on diagnostic testing that includes a 12-lead ECG and an echocardiogram. An ECG is a non-invasive test that uses electrodes placed on the surface of the chest to detect heart rhythm. An echocardiogram is a non-invasive ultrasound that visualizes the heart as it beats, potentially detecting disruptions in rhythm.

In many cases, one test alone will show the pattern consistent with bundle branch block, both tests won't be necessary.

Bundle Branch Block and ECG

An ECG is a visual representation of an electrical impulse as it moves through the heart. A computer-generated wave pattern reflecting the rhythm of the heart is produced based on electrical impulses detected with small metal electrodes placed on the chest.

The QRS complex is a portion of the ECG that represents the electrical impulse as it is being distributed by the bundle branch system throughout the ventricles.

In the figure above, Panel A shows what a normal QRS complex looks like on a normal ECG. Since both ventricles normally receive the electrical impulse at the same time, the normal QRS complex is relatively narrow (generally less than 0.1 second in duration.) The simultaneous stimulation of both ventricles depends on the electrical impulse traveling down both the right and left bundle branches at nearly the same rate of speed.

With a bundle branch block, it takes longer for the electrical signal to be completely distributed across both ventricles and the QRS complex widens.

• Panel B in the figure illustrates the characteristic changes that occur in the QRS complex when a person has a left bundle branch block. The complex widens and is deflected up.³ This change can make interpretation of an ECG less reliable when it's used to evaluate other conditions.

• Panel C in the figure illustrates the ECG changes that occur in the QRS complex with a right bundle branch block—a widened QRS wave with a downward deflection.⁷

Sometimes, both bundle branches are affected, and the bundle branch block pattern on the ECG is not clearly identifiable as either right or left bundle branch block. In this case, the bundle branch block is referred to as an “intraventricular conduction delay.”

Echocardiogram

A bundle branch block might be detected with an echocardiogram. This non-invasive test allows healthcare providers to visualize the motion and rhythm of the heart as it beats.

Although the movement and rhythm of the heart can be altered with a bundle branch block, an echocardiogram may not pinpoint the bundle branch block as the cause of these abnormalities.

More importantly, this test gives healthcare providers a detailed view of the heart. It can be used to help identify anatomical defects that are associated with a worse prognosis of bundle branch block.⁸

If you have a bundle branch block, your healthcare provider might order an echocardiogram for you so your medical team will be better able to assess the impact of your conduction disorder.

Cardiac Evaluation

Depending on your symptoms and risk factors, you might need more testing to evaluate your heart and/or lungs, although this isn't necessarily part of the evaluation of an uncomplicated bundle branch block without symptoms or risk factors. For example, you may need to have a diagnostic cardiac catheterization to evaluate the blood vessels in your heart or a stress test if you are having angina (chest pain).

Treatment

Most of the time, bundle branch block does not require treatment.¹ However, you and your healthcare provider will have to discuss your condition and determine whether your symptoms (if you have any) are caused by bundle branch block or another health condition, such as heart disease.

Occasionally, a severe bundle branch block may require the surgical placement of a pacemaker to prevent episodes of complete heart block.⁹

In addition, significant heart failure accompanied by left bundle branch block may be treated with implantation of a cardiac resynchronization therapy (CRT) device. CRT is a specialized pacemaker that re-coordinates the beating of the two ventricles and can improve cardiac efficiency in some situations.¹⁰

Associated Conditions

Also, if you have another type of heart disease along with your conduction block, the associated heart condition typically needs to be treated.

This might involve approaches like prescription blood thinners for CAD, antihypertensive medication to alleviate high blood pressure, bronchodilators to treat COPD, or surgical repair for a malfunctioning heart valve.