今日の臨床サポート

右脚ブロック

著者: 真中哲之 浅草ハートクリニック

監修: 今井靖 自治医科大学 薬理学講座臨床薬理学部門・内科学講座循環器内科学部門

著者校正済:2021/09/08
現在監修レビュー中
患者向け説明資料

概要・推奨   

  1. 虚血性心疾患、心筋症などの基礎心疾患および糖尿病、高血圧等の疾患を有する患者では、定期的に心電図検査を施行し、脚ブロックの出現に注意する(推奨度1)。 
  1. 無症候性右脚ブロックを認める場合であっても合併する基礎心疾患の有無を確認する(推奨度1)。
  1. 基礎心疾患を有するような症例では原疾患の進行、完全房室ブロックへの移行に注意し、フォローアップを行う(推奨度1)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧には
閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
真中哲之 : 未申告[2021年]
監修:今井靖 : 講演料(第一三共株式会社)[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。 

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 心室内伝導路はHis束以下の心室膜様部直下で、まず左脚が分枝しそのまま右脚に移行、心室中隔右室側心内膜下を右室前乳頭筋基部まで走行する。左脚は大動脈弁右冠尖と無冠尖の交連部下方で前乳頭筋に向かう前枝(anterior fascicle)と後乳頭筋に向かう後枝(posterior fascicle)に分枝する[1]
 
右脚、左脚の解剖

左脚(①main left bundle ②anterior fascicle ③posterior fascicle)

出典

img1:  Evolving considerations in the management of patients with left bundle branch block and suspected myocardial infarction.
 
 J Am Coll Cardiol. 2012 Jul 10;60(2):96-・・・
 
  1. His束以下の伝導系の障害を広義には「心室内伝導障害」と呼び、その中に脚ブロック、分枝ブロックなどが含まれる。
  1. WHO、国際心臓連合[International Society and Federation of Cardiology、ISFC]の基準
 
心室内伝導障害の分類

広義の心室内伝導障害は脚ブロック、分枝ブロックそのほかに分類される。

出典

img1:  Criteria for intraventricular conduction disturbances and pre-excitation. World Health Organizational/International Society and Federation for Cardiology Task Force Ad Hoc.
 
 J Am Coll Cardiol. 1985 Jun;5(6):1261-75・・・
 
  1. 右脚がブロックされると心室内の伝導様式が変化するため心電図変化がみられる。
 
右脚ブロックの出現

右脚ブロックの出現により心電図が変化する

出典

img1:  Right bundle branch block: are we looking in the right direction?
 
 Eur Heart J. 2013 Jan;34(2):86-8. doi: 1・・・
 
  1. Framingham studyでは8,396人の対象のうちQRS幅が0.10秒以上の心室内伝導障害を呈した症例は男性の6%、女性の2.4%であった[2]。約半数がQRS幅0.12秒以上の完全脚ブロックであり、50歳以上で加齢とともに増加傾向があった。また高齢者ほど左脚ブロックの占める割合が増加する傾向もみられた。
問診・診察のポイント  
  1. 年齢を確認する。心疾患のない高齢者の心室内伝導障害は特発性両脚線維症の頻度が高い。

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文献 

著者: B E Kreger, K M Anderson, W B Kannel
雑誌名: Am Heart J. 1989 Apr;117(4):903-10.
Abstract/Text QRS intervals in the ECGs of members of the Framingham Heart Study cohort and offspring were measured to provide an estimate of the prevalence of intraventricular block in the general population. Intervals of greater than or equal to 0.09 second appear in men twice as commonly as in women, are rare before age 50 to 60, and shift from a predominance of right bundle branch block in the young to an indeterminate pattern in the elderly. Complete intraventricular block (QRS interval greater than or equal to 0.12 second) is seen in 11% of elderly men and 5% of elderly women. Aside from age and sex, logistic regression indicates strong associations with concurrent manifestations of coronary heart disease, congestive heart failure, and atrioventricular block, as well as hypertension, left ventricular hypertrophy, and ventricular extrasystoles. Among those subjects free of clinical coronary disease and congestive heart failure, associations between QRS interval and age, sex, atrioventricular block, and ECG left ventricular hypertrophy remain significant by multivariate analysis. Whether people with prolonged QRS intervals need special monitoring or attention cannot be told from these data.

PMID 2784619  Am Heart J. 1989 Apr;117(4):903-10.
著者: Barbara E Bussink, Anders G Holst, Lasse Jespersen, Jaap W Deckers, Gorm B Jensen, Eva Prescott
雑誌名: Eur Heart J. 2013 Jan;34(2):138-46. doi: 10.1093/eurheartj/ehs291. Epub 2012 Sep 4.
Abstract/Text AIMS: To determine the prevalence, predictors of newly acquired, and the prognostic value of right bundle branch block (RBBB) and incomplete RBBB (IRBBB) on a resting 12-lead electrocardiogram in men and women from the general population.
METHODS AND RESULTS: We followed 18 441 participants included in the Copenhagen City Heart Study examined in 1976-2003 free from previous myocardial infarction (MI), chronic heart failure, and left bundle branch block through registry linkage until 2009 for all-cause mortality and cardiovascular outcomes. The prevalence of RBBB/IRBBB was higher in men (1.4%/4.7% in men vs. 0.5%/2.3% in women, P < 0.001). Significant predictors of newly acquired RBBB were male gender, increasing age, high systolic blood pressure, and presence of IRBBB, whereas predictors of newly acquired IRBBB were male gender, increasing age, and low BMI. Right bundle branch block was associated with significantly increased all-cause and cardiovascular mortality in both genders with age-adjusted hazard ratios (HR) of 1.31 [95% confidence interval (CI), 1.11-1.54] and 1.87 (95% CI, 1.48-2.36) in the gender pooled analysis with little attenuation after multiple adjustment. Right bundle branch block was associated with increased risk of MI with an HR of 1.67 (95% CI, 1.16-2.42) and pacemaker insertion with an HR of 2.17 (95% CI, 1.22-3.86), but not with chronic heart failure (HR 1.37; 95% CI, 0.96-1.94), atrial fibrillation (HR 1.10; 95% CI, 0.73-1.67), or chronic obstructive pulmonary disease (HR 0.99; 95% CI, 0.60-1.62). The presence of IRBBB was not associated with any adverse outcome.
CONCLUSION: In this cohort study, RBBB and IRBBB were two to three times more common among men than women. Right bundle branch block was associated with increased cardiovascular risk and all-cause mortality, whereas IRBBB was not. Contrary to common perception, RBBB in asymptomatic individuals should alert clinicians to cardiovascular risk.

PMID 22947613  Eur Heart J. 2013 Jan;34(2):138-46. doi: 10.1093/eurhea・・・
著者: Zhu-ming Zhang, Pentti M Rautaharju, Elsayed Z Soliman, Joann E Manson, Michael E Cain, Lisa W Martin, Anthony A Bavry, Laxmi Mehta, Mara Vitolins, Ronald J Prineas
雑誌名: Am J Cardiol. 2012 Nov 15;110(10):1489-95. doi: 10.1016/j.amjcard.2012.06.060. Epub 2012 Aug 2.
Abstract/Text Electrocardiographic bundle branch block (BBB) has higher cardiac and all-cause death. However, reports on the association between BBBs and mortality in the general populations are conflicting. The aim of this study was to evaluate the risk for coronary heart disease (CHD) and all-cause death associated with left BBB (LBBB) and right BBB (RBBB) during 14 years of follow-up in 66,450 participants from the Women's Health Initiative (WHI) study. Cox proportional-hazards regression was performed for mortality risk in Women with LBBB (n = 714) and those with RBBB (n = 832). In risk models adjusted for demographic and clinical risk factors in women with cardiovascular disease (CVD), hazard ratios for CHD death were 2.92 (95% confidence interval 2.08 to 4.08, p <0.001) for LBBB and 1.62 (95% confidence interval 1.08 to 2.43, p <0.05) for RBBB, and only LBBB was a significant predictor of all-cause death (hazard ratio 1.43, 95% confidence interval 1.11 to 1.83, p <0.01). In CVD-free women, only LBBB was a significant predictor of CHD death (fully adjusted hazard ratio 2.17, 95% confidence interval 1.37 to 3.43, p <0.01), and neither blocks was predictive of all-cause death. From several repolarization variables that were significant mortality predictors in univariate risk models, after adjustment for other electrocardiographic covariates and risk factors, ST J-point depression in lead aVL ≤-30 μV in women with LBBB was an independent predictor of CHD death, with a more than fivefold increase in risk. None of the repolarization variables were independent predictors in women with RBBB. In conclusion, prevalent LBBB in CVD-free women and LBBB and RBBB in women with CVD were significant predictors of CHD death. In women with LBBB, ST J-point depression in lead aVL was a strong independent predictor of CHD death.

Copyright © 2012 Elsevier Inc. All rights reserved.
PMID 22858187  Am J Cardiol. 2012 Nov 15;110(10):1489-95. doi: 10.1016・・・
著者: B Hesse, L A Diaz, C E Snader, E H Blackstone, M S Lauer
雑誌名: Am J Med. 2001 Mar;110(4):253-9.
Abstract/Text PURPOSE: Complete left bundle branch block is a well-established independent risk factor for mortality, but the prognostic importance of right bundle branch block is unclear. We determined whether left and right bundle branch block was associated with all-cause mortality risk after adjustment for potential confounders, including clinical, exercise, and nuclear scintigraphic variables.
SUBJECTS AND METHODS: We studied 7,073 adults who were referred for symptom-limited nuclear exercise testing. Patients with heart failure or pacemakers were excluded. The presence or absence of bundle branch block was determined from resting electrocardiograms. The main outcome measure was all-cause mortality during a mean of 6.7 years of follow-up.
RESULTS: One hundred ninety patients (3%) had complete right bundle branch block, and 150 (2%) had complete left bundle branch block. There were 825 deaths (12%). Mortality was greater in patients with complete right bundle branch block (24% [46 of 190]) or left bundle branch block (24% [36 of 150]) than in those without these findings (11% [779 of 6,883 and 789 of 6,923, respectively]; both P <0.0001). After adjustment for potential confounders, right bundle branch block was as strong an independent predictor of mortality (hazard ratio [HR] 1.5; 95% confidence interval [CI]: 1.1 to 2.1; P = 0.007) as left bundle branch block (HR 1.5; 95% CI: 1.0 to 2.0; P = 0.017). Incomplete right bundle branch block was not associated with mortality.
CONCLUSION: Complete right and left bundle branch block are independent predictors of all-cause mortality risk even after adjustment for exercise capacity, nuclear perfusion defects, and other risk factors.

PMID 11239842  Am J Med. 2001 Mar;110(4):253-9.
著者: R A Freedman, E L Alderman, L T Sheffield, M Saporito, L D Fisher
雑誌名: J Am Coll Cardiol. 1987 Jul;10(1):73-80.
Abstract/Text The onset of bundle branch block during acute myocardial infarction is indicative of ischemia in the distribution of the left anterior descending coronary artery. However, whether patients with chronic coronary artery disease and bundle branch block have a predominance of left anterior descending artery lesions is not known. Similarly, the prognostic implications of bundle branch block have been studied primarily in the setting of acute myocardial infarction, and the independent prognostic implications of bundle branch block in patients with chronic coronary artery disease are not known. The electrocardiograms (ECGs) of 15,609 patients with chronic coronary artery disease who underwent coronary and left ventricular angiography as part of the Coronary Artery Surgery Study (CASS) were reviewed, and 522 patients with bundle branch block were identified. Patients with bundle branch block had both more extensive coronary artery disease and worse left ventricular function than did patients without bundle branch block. However, no particular location of coronary artery stenosis or left ventricular wall motion abnormality predominated in patients with bundle branch block. During a follow-up period of 4.9 +/- 1.3 years, 2,386 patients died. Actuarial probability of mortality at 2 years in patients with left bundle branch block was more than five times that in patients without bundle branch block (p less than 0.0001), and in patients with right bundle branch block the mortality rate was approximately twice that in patients without bundle branch block (p less than 0.0001). Stepwise Cox regression analysis showed that left bundle branch block, but not right bundle branch block, was a strong predictor of mortality, independent of degree of heart failure, extent of coronary disease and other variables (p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

PMID 3597997  J Am Coll Cardiol. 1987 Jul;10(1):73-80.
著者: Glen Sumner, Omid Salehian, Qilong Yi, Jeff Healey, James Mathew, Khalid Al-Merri, Khaled Al-Nemer, J F E Mann, Gilles Dagenais, Eva Lonn, HOPE Investigators
雑誌名: J Cardiovasc Electrophysiol. 2009 Jul;20(7):781-7. doi: 10.1111/j.1540-8167.2009.01440.x. Epub 2009 Feb 27.
Abstract/Text OBJECTIVE: The prognostic significance of left and right bundle branch block (LBBB and RRBB) in patients with chronic stable cardiovascular (CV) disease is not well characterized and was evaluated in the Heart Outcomes Prevention Evaluation (HOPE) study cohort.
DESIGN: Observational analysis of data prospectively collected in the HOPE trial.
SETTING AND PATIENTS: HOPE was a multicenter, international trial, which evaluated ramipril and vitamin E in 9,541 patients aged > or = 55 years with CV disease or diabetes with > or = 1 CV risk factor(s) but without heart failure (HF) or known left ventricular systolic dysfunction. Follow-up extended for a median of 4.5 years. Electrocardiograms were obtained at baseline in all study participants and were read centrally.
MAIN OUTCOME MEASURES: Major CV events (defined as CV death, myocardial infarction, or stroke), heart failure, CV death, all-cause death, and sudden death.
RESULTS: Baseline LBBB was present in 246 (2.6%) patients and was associated with increased risk for major CV events (HR = 1.54; 95% CI, 1.18-2.02), CV death (HR 2.29; 95% CI, 1.63-3.20), heart failure (HR 2.99; 95% CI, 2.31-3.87), sudden death (HR 3.17; 95% CI, 2.13-4.73), and all-cause death (HR = 2.10; 95% CI, 1.59-2.77). In multivariate models, LBBB remained an independent predictor of heart failure, sudden death, CV death, and all-cause death (P < or = 0.002 for all). Baseline RBBB was present in 428 (4.5%) of patients and was not associated with increased CV risk.
CONCLUSIONS: In patients with stable chronic CV disease, LBBB but not RBBB is an independent predictor of heart failure, sudden death, CV death, and all-cause death.

PMID 19298567  J Cardiovasc Electrophysiol. 2009 Jul;20(7):781-7. doi:・・・
著者: M Rotman, J H Triebwasser
雑誌名: Circulation. 1975 Mar;51(3):477-84.
Abstract/Text The experience with bundle branch block at the USAF School of Aerospace Medicine was reviewed. The clinical and follow-up status was evaluated in 394 subjects with right bundle branch block (RBBB) and 125 subjects with left bundle branch block (LBBB). The majority of subjects were asymptomatic at the time of bundle branch block diagnosis. The subjects were divided into subfroups based on electrocardiographic (EEG) findings to determine if any one subfroup was at higher risk for initial or follow-up morbidity of cardiobascular disease or follow-up mortality. At initial diagnosis and clinical evaluation, 94% of RBBB and 89% of LBBB subjects had no evidence of cardiobascular disease. In the RBBB group, 3 and 2% had cornary heart disease and hypertension, respectively; in LBBB subjects, 9 and 7% had cornary heart disease and hypertension, respectively. No one ECG subfroup in either the RBBB or LBBB group had a higher incidence of cardiobascular disease. Complete follow-up information was available in 94% of the RBBB subgroup subjects and 91% of the LBBB group. In the follow-up period, new cases of coronary heart disease and hypertension occurred in 6% of the RBBB group and 5 and 8%, respectively, in the LBBB group. Fourteen (4%) RBBB and nine (8%) LBBB subjects died during the follow-up period. No differences for follow-up groups. Progressive electrical dysfunction in the form of complete heart block occurred in one subject each absence, and degree of associated cardiobascular disease. Furthermore, within the age limits of the present aeromedical implications of bundle block are discussed.

PMID 1132086  Circulation. 1975 Mar;51(3):477-84.
著者: Peter Eriksson, Lars Wilhelmsen, Annika Rosengren
雑誌名: Eur Heart J. 2005 Nov;26(21):2300-6. doi: 10.1093/eurheartj/ehi580. Epub 2005 Oct 7.
Abstract/Text AIMS: To investigate the long-term fate of men with bundle-branch block (BBB) from a general population sample.
METHODS AND RESULTS: Data were derived from 7392 men without a history of myocardial infarction or stroke, born between 1915 and 1925 and investigated between 1970 and 1973. All participants were followed from the date of their baseline examination until 1998. We identified 70 men with right-BBB and 46 men with left-BBB at baseline. In men with right-BBB, there was no increased risk of myocardial infarction, coronary death, heart failure, or all-cause mortality during follow-up. The multiple-adjusted hazard ratio for progression to high-degree atrioventricular block was 3.64 (99% confidence interval 0.79-16.72). In men with left-BBB, the hazard ratio for high-degree atrioventricular block was 12.89 (4.13-40.24). However, hazard ratio for all-cause mortality was 1.85 (1.15-2.97) when compared with men without BBB, mostly due to outside hospital coronary deaths, whose hazard ratio was 4.22 (1.90-9.34).
CONCLUSION: The presence of BBB was strongly associated with future high-degree atrioventricular block that was more pronounced for left-BBB. Men with left-BBB have a substantially increased risk of coronary death, mainly due to sudden death outside the hospital setting.

PMID 16214833  Eur Heart J. 2005 Nov;26(21):2300-6. doi: 10.1093/eurhe・・・
著者: Masayuki Taniguchi, Hajime Nakano, Koichiro Kuwahara, Izuru Masuda, Yasuhiro Okawa, Hiroshi Miyazaki, Hirofumi Okoshi, Masanobu Kaji, Yoshiko Noguchi, Ichiro Asukata
雑誌名: Intern Med. 2003 Jan;42(1):21-4.
Abstract/Text OBJECTIVE: The purpose of this study was to evaluate the prognostic and clinical significance of newly acquired complete right bundle branch block (CRBBB) in airline pilots.
PATIENTS: This study included pilots with acquired CRBBB, identified from a group of over 2,700 Japan Airline pilots. When the pilots applied for employment, a past medical history, physical examination, electrocardiogram, and chest radiograph were obtained. The pilots with ECG abnormality including CRBBB were not included in the study because of hiring requirements.
RESULTS: Thirty-six pilots with CRBBB were identified between 1983 and 2002. All pilots with CRBBB were evaluated for the presence of ischemic heart disease by treadmill exercise testing, echocardiogram and exercise thallium scintigraphy. Twelve individuals underwent coronary angiography. The mean age of pilots was 44.4 +/- 5.8 years. The mean observation period was 10.9 +/- 5.7 years. For each of the 36 study subjects, Holter electrocardiogram and echocardiogram were obtained every 6 months after the CRBBB was detected. Exercise stress testing was performed every year. Exercise thallium scintigraphy was performed every 2 years to detect ischemic heart disease. During the observation period, two pilots stopped flying temporarily because of frequent ventricular premature beats and one pilot stopped flying permanentaly because of atrial fibrillation. During the follow-up period, no cardiovascular events were observed in pilots with CRBBB who had no underlying ischemic heart disease.
CONCLUSION: Acquired CRBBB does not confer a poor prognosis, particularly in young men working as a pilot if there is no evidence of ischemia on exercise stress testing, echocardiography and exercise thallium scintigraphy.

PMID 12583613  Intern Med. 2003 Jan;42(1):21-4.
著者: Jonathan H Kim, Peter A Noseworthy, David McCarty, Kibar Yared, Rory Weiner, Francis Wang, Malissa J Wood, Adolph M Hutter, Michael H Picard, Aaron L Baggish
雑誌名: Am J Cardiol. 2011 Apr 1;107(7):1083-9. doi: 10.1016/j.amjcard.2010.11.037. Epub 2011 Feb 4.
Abstract/Text We sought to determine the clinical and physiologic significance of electrocardiographic complete right bundle branch block (CRBBB) and incomplete right bundle branch block (IRBBB) in trained athletes. The 12-lead electrocardiographic and echocardiographic data from 510 competitive athletes were analyzed. Compared to the 51 age-, sport type-, and gender-matched athletes with normal 12-lead electrocardiographic QRS complex duration, the 44 athletes with IRBBB (9%) and 13 with CRBBB (3%) had larger right ventricular (RV) dimensions, as measured by the basal RV end-diastolic diameter (CRBBB 43 ± 3 mm, IRBBB 38 ± 6 mm, normal QRS complex 35 ± 4 mm, p <0.001) and RV end-diastolic area (CRBBB 33 ± 5, IRBBB 27 ± 7, and normal QRS complex 23 ± 3 cm(2); p <0.001). Athletes with CRBBB also had a relative reduction in the RV systolic function at rest as assessed by the RV fractional area change and peak systolic tissue velocity. Finally, QRS prolongation was associated with parallel increases in interventricular dyssynchrony (basal RV to basal lateral left ventricular peak systolic tissue velocity time difference: CRBBB 112 ± 15, IRBBB 73 ± 33, normal QRS complex 43 ± 39 ms, p <0.001). Despite these findings, no athlete with CRBBB or IRBBB was found to have pathologic structural cardiac disease. In conclusion, among trained athletes, CRBBB and IRBBB appear to be markers of a structural and physiological cardiac remodeling triad characterized by RV dilation, a relative reduction in the RV systolic function at rest, and interventricular dyssynchrony.

Copyright © 2011 Elsevier Inc. All rights reserved.
PMID 21296331  Am J Cardiol. 2011 Apr 1;107(7):1083-9. doi: 10.1016/j.・・・
著者: I S Thrainsdottir, T Hardarson, G Thorgeirsson, H Sigvaldason, N Sigfusson
雑誌名: Eur Heart J. 1993 Dec;14(12):1590-6.
Abstract/Text This study is based on the Reykjavik Study, a long-term prospective cardiovascular survey, which included a representative population of 9135 men and 9627 women, 33-79 years old, who were invited to participate during the years 1967-91. Right bundle branch block (RBBB) was found in 126 men and 67 women. The prevalence increased with age, from 0% among men and women 30-39 years of age to 4.1% and 1.6% in men and women, respectively, who where 75-79 years old. The incidence increased with age. In men younger than 60 years RBBB had a significant relationship with hypertension (P < 0.05), elevated fasting blood glucose (P = 0.05), and increased heart size (P < 0.05). In men with RBBB regardless of age, an association was found with cardiomegaly (P < 0.05), ischaemic heart disease (P < 0.05), arrhythmias (P < 0.001) and bradycardia (P < 0.01). A higher mortality from heart disease (P < 0.01) was found in men with RBBB compared to the control population. This was not significant when risk factors of heart disease were taken into account by multivariate Cox analysis. There was a relationship (P < 0.05) between hypertension and RBBB in women younger than 60 years. RBBB in women younger than 60 years is often associated with hypertension and in men younger than 60 it is often associated with an underlying cardiovascular disease, hypertension, cardiomegaly and elevated blood glucose.

PMID 8131755  Eur Heart J. 1993 Dec;14(12):1590-6.
著者: G J Fahy, S L Pinski, D P Miller, N McCabe, C Pye, M J Walsh, K Robinson
雑誌名: Am J Cardiol. 1996 Jun 1;77(14):1185-90.
Abstract/Text The purpose of this study was to determine the long-term outcome of patients with bundle branch block (BBB) who have no clinical evidence of cardiovascular disease. Among 110,000 participants in a screening program, 310 subjects with BBB without apparent of suspected heart disease were identified. Their outcome after a mean follow-up of 9.5 years was compared with that of 310 similarly screened age- and sex-matched controls. Among the screened population, isolated right BBB was more prevalent than isolated left BBB (0.18% vs 0.1%, respectively; p<0.001), and the prevalence of each abnormality increased with age (p<0.001). Total actuarial survival was no different for those with left BBB or right BBB and their respective controls. Cardiac mortality, however, was increased in the left BBB group when compared with their controls (p=0.01, log rank test). Left BBB, but not right BBB, was associated with an increased prevalence of cardiovascular disease at the follow-up (21% vs 11%; p=0.04). In the absence of clinically overt cardiac disease, the presence of left BBB or right BB is not associated with increased overall mortality. Isolated left BBB is associated with an increased risk of developing overt cardiovascular disease and increased cardiac mortality.

PMID 8651093  Am J Cardiol. 1996 Jun 1;77(14):1185-90.
著者: Wayne L Miller, David O Hodge, Stephen C Hammill
雑誌名: Am J Cardiol. 2008 Jan 1;101(1):102-6. doi: 10.1016/j.amjcard.2007.07.056.
Abstract/Text Ventricular conduction blocks (VCBs) identified on a 12-lead electrocardiogram (ECG) are associated with poor outcomes in patients with known cardiac disease. The prognostic implications of uncomplicated VCB (right or left bundle branch block [RBBB or LBBB], left anterior hemiblock) in patients without cardiac diagnoses, however, need to be reevaluated in the current therapeutic era. The purpose of this study was to determine long-term cardiac morbidity and mortality in a community-based population with electrocardiographically-identified VCB, documented normal left ventricular ejection fraction, and no diagnoses of cardiac disease at the time of the index ECG. A retrospective observational cohort study was undertaken of patients in Olmsted County, Minnesota, evaluated from 1975 to 1999. Kaplan-Meier survival analysis post-index electrocardiography was performed with median follow-up of 9.0 years; 706 patients (mean age 64 +/- 16 [SE] years) were identified. Of those, 12% had LBBB with left-axis deviation (LAD); 20% had LBBB without LAD; 26% had left anterior hemiblock; and 42% had RBBB. Kaplan-Meier analysis indicated a significant difference in cardiovascular morbidity risk among the VCB groups (p = 0.017) with left anterior hemiblock and LBBB with LAD, and these were associated with the highest 10-year cardiovascular morbidity risk (58% and 68%, respectively). The incidence of dilated cardiomyopathy was 3% in patients with LBBB with LAD compared with 0.85% in the overall cohort. Significant mortality differences were also demonstrated between LBBB with LAD compared with LBBB without LAD (p = 0.048), left anterior hemiblock compared with LBBB without LAD (p <0.0001), and left anterior hemiblock compared with RBBB (p = 0.0007). In conclusion, the identification of uncomplicated VCB with LAD is associated with increased long-term cardiac morbidity/mortality risk, including the development of dilated and ischemic cardiomyopathy. Isolated VCB is an early marker of cardiac co-morbidities and potentially identifies a high-risk group of patients who warrant preventive intervention.

PMID 18157974  Am J Cardiol. 2008 Jan 1;101(1):102-6. doi: 10.1016/j.a・・・
著者: Aapo L Aro, Olli Anttonen, Jani T Tikkanen, M Juhani Junttila, Tuomas Kerola, Harri A Rissanen, Antti Reunanen, Heikki V Huikuri
雑誌名: Circ Arrhythm Electrophysiol. 2011 Oct;4(5):704-10. doi: 10.1161/CIRCEP.111.963561. Epub 2011 Aug 13.
Abstract/Text BACKGROUND: Prolonged duration of QRS complex in a 12-lead ECG is associated with adverse prognosis in patients with cardiac disease, but its significance is not well established in the general population. In particular, there is a paucity of data on the prognostic significance of nonspecific intraventricular conduction delay in apparently healthy subjects.
METHODS AND RESULTS: We evaluated the 12-lead ECGs of 10 899 Finnish middle-aged subjects from the general population (52% of whom were men; mean age 44±8.5 years) between 1966 and 1972 and followed them for 30±11 years. Primary end points were all-cause mortality, cardiac mortality, and arrhythmic death. Prolonged QRS duration was defined as QRS ≥110 ms and intraventricular conduction delay as QRS ≥110 ms, without the criteria of complete or incomplete bundle-branch block. QRS duration ≥110 ms was present in 1.3% (n=147) and intraventricular conduction delay in 0.6% (n=67) of the subjects. Prolonged QRS duration predicted all-cause mortality (multivariate-adjusted relative risk [RR] 1.48; 95% confidence interval [CI] 1.22-1.81; P<0.001), cardiac mortality (RR 1.94; CI 1.44-2.63; P<0.001), and sudden arrhythmic death (RR 2.14; CI 1.38-3.33; P=0.002). Subjects with intraventricular conduction delay had increased all-cause mortality (RR 2.01; CI 1.52-2.66; P<0.001), increased cardiac mortality (RR 2.53; CI 1.64-3.90; P<0.001), and an elevated risk of arrhythmic death (RR 3.11; CI 1.74-5.54; P=0.001). Left bundle-branch block also weakly predicted arrhythmic death (P=0.04), but right bundle-branch block was not associated with increased mortality.
CONCLUSIONS: Prolonged QRS duration in a standard 12-lead ECG is associated with increased mortality in a general population, with intraventricular conduction delay being most strongly associated with an increased risk of arrhythmic death.

PMID 21841194  Circ Arrhythm Electrophysiol. 2011 Oct;4(5):704-10. doi・・・
著者: Alon Barsheshet, Ilan Goldenberg, Moshe Garty, Shmuel Gottlieb, Amir Sandach, Avishag Laish-Farkash, Michael Eldar, Michael Glikson
雑誌名: Am J Cardiol. 2011 Feb 15;107(4):540-4. doi: 10.1016/j.amjcard.2010.10.007. Epub 2010 Dec 22.
Abstract/Text There is controversy regarding type of bundle branch block (BBB) that is associated with increased mortality risk in patients with heart failure (HF). The present study was designed to explore the association between BBB pattern and long-term mortality in hospitalized patients with systolic HF. Risk of 4-year all-cause mortality was assessed in 1,888 hospitalized patients with systolic HF (left ventricular ejection function <50%) without a pacemaker in a prospective national survey. Cox proportional hazards regression modeling was used to compare mortality risk in patients with right BBB (RBBB; 10%), left BBB (LBBB; 14%), and no BBB (76%) on admission electrocardiogram. At 4 years of follow up, mortality rates were highest in patients with RBBB (69%), intermediate in those with LBBB (63%), and lowest in those without BBB (50%, p <0.001). Multivariate analysis demonstrated a significant 36% increased mortality risk in patients with RBBB versus no BBB (p = 0.002) but no significant difference in mortality risk for patients with LBBB versus no BBB (hazard ratio 1.04, p = 0.66). RBBB versus LBBB was associated with a 29% (p = 0.035) increased risk for 4-year mortality in the total population and with a 58% (p = 0.015) increased risk in patients with ejection fraction <30%. In conclusion, RBBB but not LBBB on admission electrocardiogram is associated with a significant increased long-term mortality risk in hospitalized patients with systolic HF. Deleterious effects of RBBB compared to LBBB appear to be more pronounced in patients with more advanced left ventricular dysfunction.

Copyright © 2011 Elsevier Inc. All rights reserved.
PMID 21184999  Am J Cardiol. 2011 Feb 15;107(4):540-4. doi: 10.1016/j.・・・
著者: Peter A McCullough, Sohail A Hassan, Vinay Pallekonda, Keisha R Sandberg, David B Nori, Sandeep S Soman, Sonali Bhatt, Michael P Hudson, W Douglas Weaver
雑誌名: Int J Cardiol. 2005 Jul 10;102(2):303-8. doi: 10.1016/j.ijcard.2004.10.008.
Abstract/Text BACKGROUND: The determinants of bundle block patterns and their relationship to mortality in heart failure patients is not completely understood.
METHODS: We evaluated 2907 consecutive patients admitted to an intensive care unit with decompensated heart failure over 8 years. Clinical and echocardiographic factors were analyzed using multivariate techniques. All-cause mortality was available on greater than 99.0% of patients at a median of 23 months after discharge.
RESULTS: Right and left bundle branch blocks occurred in 211 (7.3%) and 386 (13.2%), p<0.0001. Older age, decreased left ventricular ejection fraction, and renal dysfunction were all found to be independently associated with bundle branch block patterns. Mortality rates for the subgroups of QRS<120 ms, right bundle branch block and left bundle branch block, over a mean follow-up of 23.4+/-2.6 months were 46.1%, 56.8% and 57.7%, p<0.0001 for comparison of QRS<120 ms versus either bundle pattern. Cox proportional hazards model adjusting for age, sex, ejection fraction, and renal function demonstrated graded decrements in survival in those with QRS<120 ms, right bundle branch block and left bundle branch block, p=0.03.
CONCLUSIONS: In patients hospitalized with severe heart failure, age, left ventricular dysfunction, and renal dysfunction are associated with bundle branch block patterns. When controlling for these factors, bundle branch block patterns are independently associated with slightly higher all cause mortality after discharge.

PMID 15982501  Int J Cardiol. 2005 Jul 10;102(2):303-8. doi: 10.1016/j・・・

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