The management of bifascicular block depends on the clinical presentation.

Patients with asymptomatic bifascicular block do not usually require any intervention as the overall risk of progression to complete heart block is low. They can be discharged with safety netting, once electrolyte abnormalities have been ruled out.

Chest pain with acute bifascicular block can be a manifestation of proximal occlusion of the LAD. Patients should be thoroughly investigated with cardiac markers and echocardiography.

Syncope or pre-syncope is an indication for admission and monitoring as it suggests that there may be intermittent complete heart block and a permanent pacemaker (PPM) may be indicated.

  • The ESC recommends all symptomatic patients should undergo EPS10. A dual chamber permanent pacemaker (PPM) is indicated if there are positive findings on EPS, whereas an implantable loop recorder is recommended if EPS is negative or inconclusive.
  • The ESC also suggest that a PPM can be considered in selected patients with bifascicular block and unexplained syncope without EPS, for example in elderly, frail patients, high risk patients, or those with recurrent syncopal episodes.
  • The ACC/HRS also recommend a PPM is indicated in asymptomatic patients with chronic bifascicular block and
    • intermittent 3rd degree heart block
    • type II 2nd degree AV block
    • alternating bundle branch block11
  • The ACC/HRS also recommend considering a PPM in bifascicular block in the presence of neuromuscular disease (including myotonic muscular dystrophy, Kearns-Sayre syndrome, peroneal muscular dystrophy, and Erb’s dystrophy), irrespective of symptoms.

Learning bite

All symptomatic patients should be admitted under Cardiology for consideration of a PPM.