Left Bundle Branch Block (LBBB) (2024)

ECG Diagnostic criteria

Associated features include:

• Left axis deviation (LAD);
• Poor R wave progression in precordial leads, and
• Appropriate discordance (discussed below)

Electrophysiology

In normal cardiac conduction, impulses travel equally down the left and right bundles, with the septum activated from left to right and the formation of small Q waves in lateral leads

• In LBBB, conduction delay means that impulses travel first via the right bundle branch to the RV, and then to the LV via the septum
• Septal activation is thus reversed eliminating lateral Q waves
• The overall depolarisation vector from the right to left ventricle produces tall R waves in lateral leads (I, V5-6) and deep S waves in the right precordial leads (V1-3). The delay between activation of the RV and LV produces the characteristic “M-shaped” R wave seen in lateral leads
• Delayed overall conduction time to the LV extends the QRS duration to ≥ 120 ms

ECG QRS Morphology

QRS Morphology in the Lateral Leads

The R wave in the lateral leads may be either “M-shaped”, notched, monophasic, or an RS complex

QRS Morphology in V1

The QRS complex in V1 may be either:

• rS complex (small R wave, deep S wave)
• QS complex (deep Q/S wave with no preceding R wave)

What about the ST elevation?

• Appropriate discordance refers to the fact that abnormal depolarisation should be followed by abnormal repolarisation, which appears discordant to the preceding QRS complex
• Lateral leads with tall, broad R waves will often have associated ST-segment depression and T-wave inversion, and those with deep S waves can have an allowable amount of ST elevation that does not indicate ischaemia (generally viewed as < 25% of the size of the preceding S wave)
• Any concordant ST segment change is concerning for ischaemia. For further reading, see LITFL: Sgarbossa Criteria

Causes of Left Bundle Branch Block

It is unusual for LBBB to exist in the absence of organic disease. Causes are varied and include:

• Aortic stenosis
• Ischaemic heart disease
• Hypertension
• Dilated cardiomyopathy
• Anterior MI
• Lenègre-Lev disease: primary degenerative disease (fibrosis) of the conducting system
• Hyperkalaemia
• Digoxin toxicity

New LBBB in the context of chest pain was once considered a “STEMI-equivalent” and part of the criteria for thrombolysis. However, more up-to-date data suggests that chest pain patients with new LBBB have little increased risk of acute myocardial infarction at the time of presentation.

Practice has now evolved to examining for excessive discordance or concordant ST segment changes indicative of infarction.

ECG Examples of LBBB

Example 1

Broad notched R waves are best appreciated in leads aVL and I here. There is absence of Q waves in leads V5-6.

Example 2

LBBB with AF. Note deep S waves in leads V1-3 and tall broad R waves laterally. Appropriate discordance is present.

Example 3

Incomplete LBBB

Incomplete LBBB is diagnosed when typical LBBB morphology is associated with a QRS duration <120ms.

Differential Diagnosis

• Right ventricular paced rhythms will produce a similiar morphology, as impulse conductions originate from the RV and travel across the septum to the LV as is the case in LBBB. Pacing spikes will be present. The same concepts regarding appropriate discordance apply.
• Left ventricular hypertrophy may produce a similar appearance to LBBB, with QRS widening and ST depression / T-wave inversion in the lateral leads.

Related Topics

• Left bundle branch block LBBB
• Right Bundle Branch Block RBBB
• Left anterior fascicular block LAFB
• Left posterior fascicular block LPFB
• Interventricular Conduction Delay IVCD
• Bifascicular block
• Trifascicular block
• Complete Heart block CHB

References

• Da Costa D, Brady WJ, Edhouse J. Bradycardias and atrioventricular conduction block. BMJ. 2002; 324(7336): 535-538
• Francia P, Balla C, Paneni F, Volpe M. Left bundle-branch block–pathophysiology, prognosis, and clinical management. Clin Cardiol. 2007; 30(3): 110-115
• Surawicz B et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: Intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol. 2009 Mar 17;53(11):976-81.
• Butterly S, Larsen P. Right Bundle Branch Block. HeartHQ
• Butterly S, Larsen P. Left Bundle Branch Block. HeartHQ

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

• Zimmerman FH. ECG Core Curriculum. 2023
• Mattu A, Berberian J, Brady WJ. Emergency ECGs: Case-Based Review and Interpretations, 2022
• Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
• Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
• Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
• Hampton J, Adlam D. The ECG Made Practical 7e, 2019
• Kühn P, Lang C, Wiesbauer F. ECG Mastery: The Simplest Way to Learn the ECG. 2015
• Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
• Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004

LITFL Further Reading

• 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

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10 Comments

1. Nice presentation

2. Thankyou for the clear elucidation….

3. Thank you. So, when you have a left bundle branch block, can this ever be a normal scenario? That is – nothing to worry about?

   • LBBB always indicates pathology, but is common in elderly patients and an incidental finding of LBBB on ECG in asymptomatic older patients does not warrant acute concern.

4. The vector moving towards the left does not explain the notch in V1 and V 6 , but it does explain a monophasic S and R wave in V1 and V 6. Explanation for the notch will be useful .

   • Hi Dr Ramesh,

     Thank you for your comment.

     The normal sequence of electrical excitation in cardiac muscle occurs as follows:
     1) Left to right across the interventricular septum
     2) Down the septum to the apex
     3) Along the ventricular walls to the AV groove, proceeding from endocardial to epicardial surface
     4) The last parts to be depolarised are the posterobasal portion of the LV, pulmonary conus, and uppermost portion of the septum

     Thus, if we take a notched V6 as the example:
     1) The initial R wave is due to (abnormal) right-to-left septal depolarisation
     2) Impulses subsequently travel down the septum towards the apex, producing a small S wave
     3) The second R wave is due to subsequent spread of excitation along the ventricular walls from endocardium to epicardium.

     I hope this explanation helps.

     Rob

5. Thank you very much for your reply

6. Thank you very nice explanation and presentation

7. Very easy to understand.

8. Is it right that in BBB normally T waves should be oriented opposite to the QRS terminal forces? What happens if this doesn’t happen – e.g. negative terminal forces and inverted T waves or positive terminal forces and upright T waves? Are these changes significant?

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