What Should Be Done With the Asymptomatic Patient With Right Bundle Branch Block?
2020; Wiley; Volume: 9; Issue: 19 Linguagem: Inglês
10.1161/jaha.120.018987
ISSN2047-9980
Autores Tópico(s)Cardiac Arrhythmias and Treatments
ResumoHomeJournal of the American Heart AssociationVol. 9, No. 19What Should Be Done With the Asymptomatic Patient With Right Bundle Branch Block? Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toOpen AccessEditorialPDF/EPUBWhat Should Be Done With the Asymptomatic Patient With Right Bundle Branch Block? Yochai Birnbaum, and MD, and Kjell NikusMD Yochai BirnbaumYochai Birnbaum * Correspondence to: Yochai Birnbaum, MD, One Baylor Plaza, MS: BCM620, Houston, TX 77030. E‐mail: E-mail Address: [email protected] https://orcid.org/0000-0001-7653-6328 The Section of Cardiology, , Baylor College of Medicine, , Houston, , TX , and Kjell NikusKjell Nikus https://orcid.org/0000-0002-9345-9851 Faculty of Medicine and Health Technology, , Tampere University and Heart Center, Tampere University Hospital, , Tampere, , Finland Originally published14 Sep 2020https://doi.org/10.1161/JAHA.120.018987Journal of the American Heart Association. 2020;9:e018987This article is a commentary on the followingMortality in Patients With Right Bundle‐Branch Block in the Absence of Cardiovascular DiseaseRight bundle branch block (RBBB) is frequently found in the general healthy population. RBBB is caused by diseases that affect the right bundle branch or the myocardial region, where the right bundle branch is located. Possible causes include trauma, structural changes, infiltrative diseases (eg, sarcoidosis), myocarditis, and myocardial infarction. Right ventricular pressure and/or volume overload, either acutely or chronically, can stretch the right bundle branch leading to the RBBB pattern. Lenegre disease or Lev disease (progressive cardiac conduction system diseases) can cause RBBB, especially in elderly patients. In patients with underlying heart disease causing degeneration of the conduction pathway, a tachycardia‐dependent RBBB can be seen.1RBBB is generally a slowly progressive degenerative disease of the conductive system. The incidence of RBBB increases with age, reaching up to 11.3% of the population by the age of 80 years.1 Many people with RBBB have no clinical evidence of structural heart disease or coronary artery disease. The relatively high prevalence of RBBB is related to the fragility of the right bundle branch, as RBBB often occurs after minor chest trauma2 or after right heart catheterization.3 Traditionally, it was accepted that in patients without evidence of cardiac disease, complete or incomplete RBBB usually is not associated with increased risk of cardiac morbidity or mortality; however, this was based on a small cohorts of patients.1, 4, 5Yet, over the years, conflicting data have emerged about the long‐term prognostic significance of incidental RBBB in people without overt cardiac disease. Rotman and Triebwasser used the database of the US Air Force Central Electrocardiographic Library and reported on 394 individuals with RBBB with a mean age of 36.9 years (range, 17–58 years). Most of the subjects were asymptomatic at the time of diagnosis. During a mean follow‐up of 10.8 years, 6% of the patients developed coronary artery disease and 4% died. Only one patient developed complete heart block. They concluded that, overall, the prognosis was good.4 No increased mortality was reported in patients >85 years with RBBB.6 Casiglia et al assessed the implications of BBB on mortality among 2254 elderly subjects included in the CASTEL (Cardiovascular Study in the Elderly) who were followed up for 7 years.7 The presence of RBBB was associated with increased all‐cause mortality in both men and women and with cardiovascular mortality only in men, but not in women.7 Fahy et al reported on 310 individuals with bundle branch block (BBB) who were followed up for 9.5 years. Left BBB, but not RBBB, was associated with an increased prevalence of cardiovascular disease at the follow‐up (21% versus 11%; P=0.04).8Eriksson et al used the Primary Prevention Study in Goteborg, Sweden. They included 7392 men without prior myocardial infarction or stroke born between 1915 and 1925 and initially evaluated between 1970 and 1973 (70 men had RBBB).9 The patients were followed up until 1998. RBBB was not associated with increased risk of myocardial infarction, cardiovascular mortality, all‐cause mortality, or heart failure. Yet, RBBB was associated with an increased risk for progression to high‐degree atrioventricular block.9Among the 9541 patients aged ≥55 years with established cardiovascular disease or diabetes mellitus with ≥1 risk factors who participated in the Heart Outcomes Prevention Evaluation trial and were followed up for a median of 4.5 years, a total of 428 (4.5%) had RBBB on their baseline ECG.10 RBBB was not associated with increased risk of cardiovascular events.10Bansilal et al studied a cohort of 2271 consecutive patients who presented to 3 Olmsted County, Minnesota, emergency departments with angina from 1985 to 1992. Over a median follow‐up of 7.3 years, the patients with RBBB had a higher risk for major adverse cardiac events (hazard ratio [HR], 1.85; 95% CI, 1.44–2.38; P<0.001) compared with patients without BBB. The survival rate after a median follow‐up of 16.6 years was lower in patients with RBBB (23% versus 53%; HR, 2.19; 95% CI, 1.73–2.78; P<0.001); however, after adjustment for baseline risk factors, the risk associated with RBBB was no longer significant (HR, 1.10; 95% CI, 0.86–1.40; P=0.45).11Zhang et al studied the prognostic significance of RBBB in women, using the WHI (Women's Health Initiative) study. A total of 66 450 women (832 with RBBB) were followed up for 14 years. The adjusted HR for coronary heart disease mortality with RBBB was 1.62 (95% CI, 1.08–2.43; P 50%) of patients, the reason for the test was screening for coronary artery disease, whereas only ≈30% had symptoms. The index stress test was positive for ischemia in only 4.8% of the patients without RBBB and in 3.2% of the patients with RBBB. Yet, the presence of RBBB was associated with a significant increased risk for all‐cause and cardiovascular mortality. The exact causes of cardiovascular death are not specified (coronary artery disease, heart failure, or arrhythmic death); thus, we cannot conclude whether the sensitivity of the stress test for detection of ischemia is low in the presence of RBBB, or that non–ischemia‐related causes were more prevalent as a cause of death in these patients.If patients with concomitant imaging stress test had been included, reporting the data could have shed light on the issue of sensitivity to detect ischemia. Confirming the findings in previous studies, Gaba et al18 reported that patients with RBBB were older than those without RBBB. In addition, peak heart rate was significantly lower and metabolic equivalents achieved was significantly lower. The percentage of the patients reaching target heart rate and the average percentage of the age‐adjusted maximal heart rate reached are not reported. With an average peak heart rate of 134.4 beats per minute and average age of 59 years (Tables 1 and 3), it is possible that a higher percentage of patients with RBBB did not reach target heart rate and, therefore, significant ischemia could have been missed. Moreover, patients with RBBB often have ST depression in the right precordial leads that become deeper during exercise. Isolated ST depression in V1 to V3 in patients with RBBB is usually not interpreted as a sign of ischemia. Studying a cohort of patients who underwent pharmacologic stress test could answer the question of whether RBBB at rest is associated with extensive coronary artery disease and worse prognosis, as was recently suggested for patients with acute coronary syndromes.19, 20, 21In the current cohort, patients with RBBB had lower exercise capacity, had slower heart rate recovery, and more often need to stop the test because of dyspnea compared with the patients without RBBB.18 Thus, RBBB can be a marker for underlying subclinical cardiac conditions, including diastolic dysfunction with preserved systolic function; hypertension was more frequent in the patients with RBBB than in those without.In addition, it is unclear whether the study included only patients with RBBB at baseline ECG in the RBBB group or also those with exercise‐induced RBBB. Stein et al reported that the mortality of patients with exercise‐induced RBBB during a stress test is relatively high.22 However, these patients were older and had significantly more comorbidities than patients without exercise‐induced RBBB. After adjusting for age, exercise‐induced RBBB was no longer significantly associated with all‐cause mortality or cardiovascular mortality.22Moreover, the authors did not analyze patients with isolated RBBB versus those with concomitant fascicular blocks (see above). Thus, we do not know if it is the RBBB itself or only RBBB associated with fascicular block that predicts mortality.Thus, the current study of mostly asymptomatic patients added an important piece of information about the long‐term significance of RBBB in patients without known heart disease; yet, it has not solved the mystery as to the underlying pathophysiological characteristics and the mechanism of increased mortality in these patients.DisclosuresNone.Footnotes* Correspondence to: Yochai Birnbaum, MD, One Baylor Plaza, MS: BCM620, Houston, TX 77030. E‐mail: [email protected]eduThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Disclosures, see page 3.See Article by Gaba et al.References1 Harkness WT, Hicks M. Right bundle branch block (RBBB). In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2020.Google Scholar2 Kumpuris AG, Casale TB, Mokotoff DM, Miller RR, Luchi RJ. Right bundle‐branch block: occurrence following nonpenetrating chest trauma without evidence of cardiac contusion. JAMA. 1979; 242:172–173.CrossrefMedlineGoogle Scholar3 Shaik FA, Slotwiner DJ, Gustafson GM, Dai X. Intra‐procedural arrhythmia during cardiac catheterization: a systematic review of literature. World J Cardiol. 2020; 12:269–284.CrossrefMedlineGoogle Scholar4 Rotman M, Triebwasser JH. A clinical and follow‐up study of right and left bundle branch block. Circulation. 1975; 51:477–484.LinkGoogle Scholar5 Iacovino JR. Mortality analysis of complete right and left bundle branch block in a selected community population. J Insur Med. 1997; 29:91–100.MedlineGoogle Scholar6 Rajala S, Haavisto M, Kaltiala K, Mattila K. ECG findings and survival in very old people. Eur Heart J. 1985; 6:247–252.CrossrefMedlineGoogle Scholar7 Casiglia E, Spolaore P, Ginocchio G, Marchioro M, Mazza A, di Menza G, Maniati G, Daskalakis C, Colangeli G, Ambrosio GB. Mortality in relation to Minnesota code items in elderly subjects: sex‐related differences in a cardiovascular study in the elderly. Jpn Heart J. 1993; 34:567–577.CrossrefMedlineGoogle Scholar8 Fahy GJ, Pinski SL, Miller DP, McCabe N, Pye C, Walsh MJ, Robinson K. Natural history of isolated bundle branch block. Am J Cardiol. 1996; 77:1185–1190.CrossrefMedlineGoogle Scholar9 Eriksson P, Wilhelmsen L, Rosengren A. Bundle‐branch block in middle‐aged men: risk of complications and death over 28 years: the Primary Prevention Study in Goteborg, Sweden. Eur Heart J. 2005; 26:2300–2306.CrossrefMedlineGoogle Scholar10 Sumner G, Salehian O, Yi Q, Healey J, Mathew J, Al‐Merri K, Al‐Nemer K, Mann JF, Dagenais G, Lonn E, et al. The prognostic significance of bundle branch block in high‐risk chronic stable vascular disease patients: a report from the HOPE trial. J Cardiovasc Electrophysiol. 2009; 20:781–787.CrossrefMedlineGoogle Scholar11 Bansilal S, Aneja A, Mathew V, Reeder GS, Smars PA, Lennon RJ, Wiste HJ, Traverse K, Farkouh ME. Long‐term cardiovascular outcomes in patients with angina pectoris presenting with bundle branch block. Am J Cardiol. 2011; 107:1565–1570.CrossrefMedlineGoogle Scholar12 Zhang ZM, Rautaharju PM, Soliman EZ, Manson JE, Cain ME, Martin LW, Bavry AA, Mehta L, Vitolins M, Prineas RJ. Mortality risk associated with bundle branch blocks and related repolarization abnormalities (from the Women's Health Initiative [WHI]). Am J Cardiol. 2012; 110:1489–1495.CrossrefMedlineGoogle Scholar13 Zhang ZM, Rautaharju PM, Soliman EZ, Manson JE, Martin LW, Perez M, Vitolins M, Prineas RJ. Different patterns of bundle‐branch blocks and the risk of incident heart failure in the Women's Health Initiative (WHI) study. Circ Heart Fail. 2013; 6:655–661.LinkGoogle Scholar14 Bussink BE, Holst AG, Jespersen L, Deckers JW, Jensen GB, Prescott E. Right bundle branch block: prevalence, risk factors, and outcome in the general population: results from the Copenhagen City Heart Study. Eur Heart J. 2013; 34:138–146.CrossrefMedlineGoogle Scholar15 Zhang ZM, Rautaharju PM, Prineas RJ, Loehr L, Rosamond W, Soliman EZ. Ventricular conduction defects and the risk of incident heart failure in the Atherosclerosis Risk in Communities (ARIC) Study. J Card Fail. 2015; 21:307–312.CrossrefMedlineGoogle Scholar16 Alventosa‐Zaidin M, Guix Font L, Benitez Camps M, Roca Saumell C, Pera G, Alzamora Sas MT, Fores Raurell R, Rebagliato Nadal O, Dalfo‐Baque A, Brugada TJ. Right bundle branch block: prevalence, incidence, and cardiovascular morbidity and mortality in the general population. Eur J Gen Pract. 2019; 25:109–115.CrossrefMedlineGoogle Scholar17 Rankinen J, Haataja P, Lyytikainen LP, Huhtala H, Lehtimaki T, Kahonen M, Eskola M, Perez‐Riera AR, Jula A, Rissanen H, et al. Long‐term outcome of intraventricular conduction delays in the general population. Ann Noninvasive Electrocardiol. 2020:e12788. DOI: 10.1111/anec.12788. [online published ahead of print].MedlineGoogle Scholar18 Gaba P, Pedrotty D, DeSimone CV, Bonikowske AR, Allison TG, Kapa S. Mortality in patients with right bundle branch block in the absence of cardiovascular disease. J Am Heart Assoc. 2020; 9:e017430. DOI: 10.1161/JAHA.120.017430.LinkGoogle Scholar19 Birnbaum Y, Fiol M, Nikus K, Niebla JG, Bacharova L, Dubner S, Zareba W, Macfarlane PW, Ribeiro AL, Cygankiewicz I, et al. A counterpoint paper: comments on the electrocardiographic part of the 2018 Fourth Universal Definition of Myocardial Infarction. J Electrocardiol. 2020; 60:142–147.CrossrefMedlineGoogle Scholar20 Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli‐Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST‐segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST‐segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39:119–177.CrossrefMedlineGoogle Scholar21 Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD; European Society of Cardiology Scientific Document Group . Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019; 40:237–269.CrossrefMedlineGoogle Scholar22 Stein R, Nguyen P, Abella J, Olson H, Myers J, Froelicher V. Prevalence and prognostic significance of exercise‐induced right bundle branch block. Am J Cardiol. 2010; 105:677–680.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesMortality in Patients With Right Bundle‐Branch Block in the Absence of Cardiovascular DiseasePrakriti Gaba, et al. Journal of the American Heart Association. 2020;9 October 6, 2020Vol 9, Issue 19Article InformationMetrics Download: 27,975 Copyright © 2020 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.120.018987PMID: 32924752 Originally publishedSeptember 14, 2020 Keywordsprognosiselectrocardiographyright bundle branch blockmortalityEditorialsPDF download SubjectsCardiovascular DiseaseElectrophysiologyEpidemiology
Referência(s)