- Normally the septum is activated from left to right, producing small Q waves in the lateral leads.
- In LBBB, the normal direction of septal depolarisation is reversed (becomes right to left), as the impulse spreads first to the RV via the right bundle branch and then to the LV via the septum.
- This sequence of activation extends the QRS duration to > 120 ms and eliminates the normal septal Q waves in the lateral leads.
- The overall direction of depolarisation (from right to left) produces tall R waves in the lateral leads (I, V5-6) and deep S waves in the right precordial leads (V1-3), and usually leads to left axis deviation.
- As the ventricles are activated sequentially (right, then left) rather than simultaneously, this produces a broad or notched (‘M’-shaped) R wave in the lateral leads.
- QRS duration of > 120 ms
- Dominant S wave in V1
- Broad monophasic R wave in lateral leads (I, aVL, V5-V6)
- Absence of Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in aVL)
- Prolonged R wave peak time > 60ms in left precordial leads (V5-6)
- Appropriate discordance: the ST segments and T waves always go in the opposite direction to the main vector of the QRS complex
- Poor R wave progression in the chest leads
- Left axis deviation
QRS Morphology in the Lateral Leads
- RS complex
QRS Morphology in V1
- rS complex (small R wave, deep S wave)
- QS complex (deep Q/S wave with no preceding R wave)
- Aortic stenosis
- Ischaemic heart disease
- Dilated cardiomyopathy
- Anterior MI
- Primary degenerative disease (fibrosis) of the conducting system (Lenegre disease)
- Digoxin toxicity
NB. It is unusual for left bundle branch block to exist in the absence of organic disease.
New LBBB in the context of chest pain is traditionally considered part of the criteria for thrombolysis. However, more recent data suggests that chest pain patients with new LBBB have little increased risk of acute myocardial infarction at the time of presentation.
- Incomplete LBBB is diagnosed when typical LBBB morphology is associated with a QRS duration < 120ms.
- Left ventricular hypertrophy may produce a similar appearance to LBBB, with QRS widening and ST depression / T-wave inversion in the lateral leads.
More Examples of LBBB
- Da Costa D, Brady WJ, Edhouse J. Bradycardias and atrioventricular conduction block. BMJ. 2002 Mar 2;324(7336):535-8. Review. PMID: 11872557. Full text.
- Hampton, JR. The ECG In Practice, 6e
- Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric, 6e
- Wagner, GS. Marriott’s Practical Electrocardiography 12e
- Chan, TC. ECG in Emergency Medicine and Acute Care
- Mattu, A. ECG’s for the Emergency Physician
LITFL Further Reading
- ECG BASICS — Waves, Intervals, Segments and Clinical Interpretation
- ECG A to Z by diagnosis –alphabetical diagnostic approach to the ECG
- ECG CLINICAL CASES — ECG’s placed in clinical context with a challenging Q&A approach
- 100 ECG Quiz — Self-assessment tool for examination practice
- ECG Reference SITES and BOOKS — the best of the rest
- LITFL ECG IMAGE Database — Searchable database of LITFL ECG’s
- ECG and Cardiology Eponymous Syndromes — Cheats guide to eponymous emancipation
- ECG Exam Template — a framework for answering ECG exam questions.