Exercise-Induced Complete Heart Block and Sinoatrial Exit Block in Baseline Bifascicular Block

BACKGROUND Bifascicular block is typically asymptomatic and incidentally diagnosed, yet it may progress to advanced conduction disturbances. In patients with unexplained syncope and conduction abnormalities, exercise stress testing can diagnose transient conduction disease. While not routinely indicated for known atrioventricular block, stress testing may clarify etiology in patients without resting high-grade block. We present a case of syncope in a patient with bifascicular block, in whom exercise stress testing revealed complete atrioventricular block and sinoatrial exit block. CASE REPORT A 72-year-old man with chronic right bundle branch block and left anterior fascicular block presented with recurrent exertional syncope. Baseline electrocardiogram revealed bifascicular block, prompting exercise stress testing. During transition from Stage 1 to Stage 2 of the Bruce protocol, he developed transient complete atrioventricular block and near-syncope, followed by Mobitz II atrioventricular block and repetitive sinoatrial Wenckebach block during recovery. Computed tomography coronary angiography showed no obstructive lesions. A dual-chamber permanent pacemaker was subsequently implanted. Follow-up showed minimal pacing, and resolution of symptoms. CONCLUSIONS This case highlights the diagnostic utility of exercise stress testing in patients with conduction abnormalities and unexplained syncope. The concurrent occurrence of atrioventricular block and sinoatrial exit block during stress testing is rare. This directly guided our management. Stress testing reproduced transient high-grade atrioventricular block and sinoatrial exit block, and preceded progressive conduction deterioration over 4 years, to near-continuous ventricular pacing. Stress testing provides symptom-electrocardiogram correlation; the provoked atrioventricular block may indicate advanced conduction-system disease progression, and documentation of syncope with high-grade block supports timely pacing.