6/15/23, 6:55 PM Bifascicular Block • LITFL • ECG Library Diagnosis

Bifascicular Block
Ed Burns and Robert Buttner ● Dec 9, 2021

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Diagnostic criteria

Clinically, bifascicular block presents with one of two ECG patterns:

Right bundle branch block (RBBB) with left anterior fascicular block (LAFB),
manifested as left axis deviation (LAD)
RBBB and left posterior fascicular block (LPFB), manifested as right axis deviation
(RAD) in the absence of other causes

*Some authors describe Left bundle branch block (LBBB) as a bifascicular block, as it may
indicate LAFB + LPFB. However, clinically the term bifascicular block is reserved for RBBB with
either LAFB or LPFB

Electrophysiology

Bifascicular block involves conduction delay below the atrioventricular node in

two of the three fascicles:

Conduction to the ventricles is via the single remaining fascicle

The ECG will show typical features of RBBB plus either left or right axis deviation.
RBBB + LAFB is the most common of the two patterns. This is due to a single coronary
artery blood supply (LAD) to the anterior fascicle

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RBBB + LPFB is less common due to a dual blood supply (right and left circumflex
arteries), and this combination may be associated with more extensive underlying cardiac
pathology

Typical bifascicular block pattern: RBBB combined with LAFB (manifested as LAD)

Clinical significance

Bifascicular block is often associated with structural heart disease (50-80%) and extensive
fibrosis of the conducting system. There is a risk of progression to complete heart block
with additional damage to the third remaining fascicle, however clinical context is important:

Overall rate of progression to complete heart block is 1-4% per year

In symptom free patients, these figures are ~1% per year
Patients presenting with syncope have a 17% annual risk of progression
Syncope or presyncope in the context of a bifascicular block is an indication for
admission and monitoring. If other causes of syncope are not identified on work-up,
pacemaker insertion is recommended

Main Causes of Bifascicular Block

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Causes are similiar to those of RBBB and LAFB/LPFB:

Ischaemic heart disease (40-60% cases)

Structural heart disease (50-80% association)
Aortic stenosis
Anterior MI (occurs in 5-7% of acute AMI)
Lenègre-Lev disease
Congenital heart disease
Hyperkalaemia (resolves with treatment)

A new-onset bifascicular block in the context of chest pain is highly associated with
proximal LAD occlusion, even in the absence of ST-segment changes. In 30% of cases,
patients present with no ST elevation and bifascicular block is the only acute ECG finding.

Differential diagnosis

Masquerading Bundle Branch Block (MBBB) presents with a mixed complete RBBB and
complete LBBB pattern similar to a typical bifascicular block pattern. This rare ECG
pattern indicates more extensive fibrosis of the conducting system and limited studies
demonstrate a poorer prognosis and higher progression to complete heart block
In the context of RBBB, RAD indicating LPFB may be due to other causes such as right
ventricular hypertrophy, and these need to be excluded before the ECG is labelled
bifascicular block

ECG examples

Example 1

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RBBB with LAFB

RBBB pattern in precordial leads with RSR’ complex in V1-2

Prominent LAD indicating LAFB

Example 2

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RBBB with LAFB, in the context of chest pain

RBBB is seen with RSR’ pattern in V1-3 and slurred S waves in lateral leads
There are concordant ST segment changes best seen in V2, and hyper-acute T waves
inferiorly.
This patient was found to have a 99% proximal LAD occlusion. See OMI: Replacing the
STEMI misnomer for further case details

Example 3a

Modified example by Prof. Dr. Johnson Francis

RBBB with LPFB

RBBB with wide QRS, slurred S wave in lead I and slurred R in V1.
Right axis deviation (dominant negative deflection in leads I and aVl) with dominant
positive deflection in aVf along with rS pattern in lead I and qR pattern leads III and aVf,
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suggesting left posterior fascicular block.

Example 3b

RBBB with LPFB and RAD

Related Topics

Left anterior fascicular block

Left bundle branch block
Left posterior fascicular block
Right bundle branch block
Trifascicular block

References

Olshansky B. Bradyarrhythmias – Conduction System Abnormalities. In: Arrhythmia

Essentials 2e, 2017.

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Vijayaraman P. Clinical Cardiac Pacing, Defibrillation and Resynchronisation Therapy 5e,

2017
Goldberger A. Ventricular Conduction Disturbances.. In: Goldberger’s Clinical
Electrocardiography 9e, 2018.

Advanced Reading
Online

Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics.
Medmastery
Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert.
Medmastery
Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG interpretation.
Medmastery
Rawshani A. Clinical ECG Interpretation ECG Waves
Smith SW. Dr Smith’s ECG blog.

Textbooks

Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care.
2e, 2019
Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
Hampton J. The ECG Made Practical 7e, 2019
Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography
1e, 2009
Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric
6e, 2008
Mattu A, Brady W. ECG’s for the Emergency Physician Part I 1e, 2003 and Part II
Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004
Smith SW. The ECG in Acute MI. 2002 [PDF]

LITFL Further Reading

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ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation

ECG A to Z by diagnosis – ECG interpretation in clinical context
ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
100 ECG Quiz – Self-assessment tool for examination practice
ECG Reference SITES and BOOKS – the best of the rest

ECG LIBRARY
Electrocardiogram

EKG Library

Ed Burns
Emergency Physician in Prehospital and Retrieval Medicine in Sydney,
Australia. He has a passion for ECG interpretation and medical education |
ECG Library |

Robert Buttner
MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric
Emergency Medicine Advanced Trainee in Melbourne, Australia. Special
interests in diagnostic and procedural ultrasound, medical education, and
ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter:
@rob_buttner

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