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Bundle branch blocks and/or hemiblocks complicating acute myocardial ischemia or infarction

¹Aix-Marseille Université, School of Medicine, 2, Place Delibes, 13008, Marseille, France. samuel@samuel-levy.com.

Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing

|August 24, 2018

Insights

Left anterior hemiblock (LAH) and left posterior hemiblock (LPH) are often linked to coronary artery disease (CAD). These conditions, especially when combined with right bundle branch block (RBBB), indicate poor prognosis in myocardial infarction but improve with timely treatment.

Area of Science:

Cardiology
Electrophysiology
Cardiovascular Pathology

Background:

The left bundle branch of the His bundle is anatomically described with three fascicles, yet a bifascicular model is widely used for practical teaching.
Left anterior hemiblock (LAH) and left posterior hemiblock (LPH) represent blocks in specific fascicles, with LAH being more common and often co-occurring with right bundle branch block (RBBB).
Coronary artery disease (CAD) is a significant etiological factor for hemiblocks.

Purpose of the Study:

To review and discuss the relationship between hemiblocks and coronary artery disease (CAD).
To examine the prevalence of LAH in patients with significant coronary lesions.
To explore the implications of bifascicular blocks in acute myocardial infarction and their association with prognosis.

Main Methods:

Review of existing literature and anatomical evidence.
Analysis of prevalence data of LAH in patients undergoing coronary angiography with significant coronary lesions.
Examination of clinical outcomes and prognostic factors associated with hemiblocks and bifascicular blocks in acute myocardial infarction.

Main Results:

A significant correlation was found between LAH and lesions in the left anterior descending coronary artery, often accompanied by impaired left ventricular function.
Bifascicular blocks (RBBB with LAH or LPH) are associated with acute myocardial infarction, poor prognosis, and heart failure.
Transient LAH patterns were observed during angina, suggesting ischemia due to CAD affecting the left anterior descending artery.
While treatments like thrombolysis and angioplasty have improved outcomes, bifascicular blocks in acute myocardial infarction still portend a less favorable prognosis due to comorbidities.

Conclusions:

Coronary artery disease is a primary cause of LAH and LPH.
Bifascicular blocks, particularly in the context of acute myocardial infarction, signify a high-risk patient group.
Improved revascularization strategies have positively impacted the prognosis of patients with bifascicular blocks during acute myocardial infarction, though challenges remain.

Read full analysis

Abstract:

Despite the bulk of anatomical and histologic evidence supporting the existence of three fascicules in the left branch of the His bundle, the concept of a bifascicular system proposed by Rosenbaum and his school has been adopted by the cardiological community as a practical teaching tool. Left anterior hemiblock (LAH) refers to block of the antero-superior branch of the left branch which is small and left posterior hemiblock (LPH) to block of the postero-inferior branch which is larger. The LAH is more common that the LPH and often associated with a complete right bundle branch block (RBBB). Coronary artery disease (CAD) is a major cause of hemiblocks. In this review article, we discuss various aspects of the relation of hemiblocks with CAD. We looked at the prevalence of LAH in consecutive patients undergoing coronary angiography and who had a significant coronary lesion in one vessel or more. In all patients with LAH, a significant lesion of the left anterior descending coronary artery was present, with in the majority of patients, an impairment of the left ventricular function. Bifascicular block (RBBB with LAH or LPH) can complicate acute myocardial infarction and is often associated with a poor prognosis and the presence of heart failure. Thrombolysis and or early angioplasty in acute myocardial infarction have significantly improved the prognosis and reduced the mortality associated with bifascicular block. Left anterior hemiblock pattern was also observed during angina pectoris occurring at rest or induced by exercise or atrial pacing. In these circumstances, LAH is transient and is likely to be due to ischemia in the anterolateral wall related to a lesion of the main trunk or the proximal left anterior descending coronary artery with the postero-inferior wall being first depolarized. The presence of bifascicular block in acute myocardial infarction still is associated with an unfavorable prognosis as compared to non-bundle branch block patients because of the common association with heart failure and other comorbidities.

Keywords:

Angina pectoris Atrioventricular block Bifascicular block Left anterior hemiblock Left posterior hemiblock Right bundle branch block

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