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Fascicular heart blocks and risk of adverse cardiovascular outcomes: Results from a large primary care population

  • Benjamin Chris Nyholm
    Correspondence
    Address reprint requests and correspondence: Dr Benjamin Chris Nyholm, Department of Cardiology, The Heart Center, Copenhagen University Hospital–Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
    Affiliations
    Department of Cardiology, The Heart Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
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  • Jonas Ghouse
    Affiliations
    Department of Cardiology, The Heart Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark

    Laboratory for Molecular Cardiology, The Heart Centre, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark
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  • Christina Ji-Young Lee
    Affiliations
    Department of Cardiology, Copenhagen University Hospital–Herlev-Gentofte, Hellerup, Denmark

    Department of Cardiology, Copenhagen University Hospital–Nordsjaellands Hospital, Hilleroed, Denmark
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  • Peter Vibe Rasmussen
    Affiliations
    Laboratory for Molecular Cardiology, The Heart Centre, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark

    Department of Cardiology, Copenhagen University Hospital–Herlev-Gentofte, Hellerup, Denmark
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  • Adrian Pietersen
    Affiliations
    Copenhagen General Practitioners’ Laboratory, Copenhagen, Denmark
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  • Steen Møller Hansen
    Affiliations
    Department of Cardiology, Copenhagen University Hospital–Nordsjaellands Hospital, Hilleroed, Denmark
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  • Christian Torp-Pedersen
    Affiliations
    Department of Cardiology, Copenhagen University Hospital–Nordsjaellands Hospital, Hilleroed, Denmark
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  • Lars Køber
    Affiliations
    Laboratory for Molecular Cardiology, The Heart Centre, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark

    Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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  • Stig Haunsø
    Affiliations
    Department of Cardiology, The Heart Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark

    Laboratory for Molecular Cardiology, The Heart Centre, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark

    Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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  • Morten Salling Olesen
    Affiliations
    Department of Cardiology, The Heart Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark

    Laboratory for Molecular Cardiology, The Heart Centre, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark

    Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
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  • Jesper Hastrup Svendsen
    Affiliations
    Department of Cardiology, The Heart Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark

    Laboratory for Molecular Cardiology, The Heart Centre, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark

    Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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  • Claus Graff
    Affiliations
    Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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  • Anders Gaarsdal Holst
    Affiliations
    Laboratory for Molecular Cardiology, The Heart Centre, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark
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  • Jonas Bille Nielsen
    Affiliations
    Laboratory for Molecular Cardiology, The Heart Centre, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark

    Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark

    K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
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  • Morten Wagner Skov
    Affiliations
    Department of Cardiology, The Heart Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark

    Laboratory for Molecular Cardiology, The Heart Centre, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark
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Published:October 18, 2021DOI:https://doi.org/10.1016/j.hrthm.2021.09.041

      Background

      Fascicular heart blocks can progress to complete heart blocks, but this risk has not been evaluated in a large general population.

      Objective

      The purpose of this study was to investigate the association between various types of fascicular blocks diagnosed by electrocardiographic (ECG) readings and the risk of incident higher degree atrioventricular block (AVB), syncope, pacemaker implantation, and death.

      Methods

      We studied primary care patients referred for ECG recording between 2001 and 2015. Cox regression models were used to estimate hazard ratios (HRs) as well as absolute risks of cardiovascular outcomes.

      Results

      Of 358,958 primary care patients (median age 54 years; 55% women), 13,636 (3.8%) had any type of fascicular block. Patients were followed up to 15.9 years. We found increasing HRs of incident syncope, pacemaker implantation, and third-degree AVB with increasing complexity of fascicular block. Compared with no block, isolated left anterior fascicular block (LAFB) was associated with 0%–2% increased 10-year risk of developing third-degree AVB (HR 1.6; 95% confidence interval [CI] 1.25–2.05), whereas right bundle branch block combined with LAFB and first-degree AVB was associated with up to 23% increased 10-year risk (HR 11.0; 95% CI 7.7–15.7), depending on age and sex group. Except for left posterior fascicular block (HR 2.09; 95% CI 1.87–2.32), we did not find any relevant associations between fascicular block and death.

      Conclusion

      We found that higher degrees of fascicular blocks were associated with increasing risk of syncope, pacemaker implantation, and complete heart block, but the association with death was negligible.

      Keywords

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      References

        • Rosenbaum M.B.
        • Elizari M.V.
        • Lazzari J.
        • Nau G.J.
        • Levi R.J.
        • Halpern M.S.
        Intraventricular trifascicular blocks. Review of the literature and classification.
        Am Heart J. 1969; 78: 450-459
        • Kusumoto F.M.
        • Schoenfeld M.H.
        • Barrett C.
        • et al.
        2018 ACC/AHA/HRS Guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
        Heart Rhythm. 2018; 16: e128-e226
        • Surawicz B.
        • Childers R.
        • Deal B.J.
        • et al.
        AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology.
        J Am Coll Cardiol. 2009; 53: 976-981
        • Brignole M.
        • Moya A.
        • de Lange F.J.
        • et al.
        2018 ESC Guidelines for the diagnosis and management of syncope.
        Eur Heart J. 2018; 39: 1883-1948
        • Nielsen J.B.
        • Strandberg S.E.
        • Pietersen A.
        • Graff C.
        • Holst A.G.
        Left anterior fascicular block and the risk of cardiovascular outcomes.
        JAMA Intern Med. 2014; 174: 1001-1003
        • Gronda M.
        • Magnani A.
        • Occhetta E.
        • et al.
        Electrophysiological study of atrio-ventricular block and ventricular conduction defects. Prognostic and therapeutical implications.
        G Ital Cardiol. 1984; 14: 768-773
        • Kaul U.
        • Dev V.
        • Narula J.
        • Malhotra A.K.
        • Talwar K.K.
        • Bhatia M.L.
        Evaluation of patients with bundle branch block and "unexplained" syncope: a study based on comprehensive electrophysiologic testing and ajmaline stress.
        Pacing Clin Electrophysiol. 1988; 11: 289-297
        • Bergfeldt L.
        • Edvardsson N.
        • Rosenqvist M.
        • Vallin H.
        • Edhag O.
        Atrioventricular block progression in patients with bifascicular block assessed by repeated electrocardiography and a bradycardia-detecting pacemaker.
        Am J Cardiol. 1994; 74: 1129-1132
        • Moya A.
        • Garcia-Civera R.
        • Croci F.
        • et al.
        Diagnosis, management, and outcomes of patients with syncope and bundle branch block.
        Eur Heart J. 2011; 32: 1535-1541
        • Kalscheur M.M.
        • Donateo P.
        • Wenzke K.E.
        • et al.
        Long-term outcome of patients with bifascicular block and unexplained syncope following cardiac pacing.
        Pacing Clin Electrophysiol. 2016; 39: 1126-1131
        • Nielsen J.B.
        • Graff C.
        • Pietersen A.
        • et al.
        J-shaped association between QTc interval duration and the risk of atrial fibrillation: results from the Copenhagen ECG study.
        J Am Coll Cardiol. 2013; 61: 2557-2564
        • Skov M.W.
        • Rasmussen P.V.
        • Ghouse J.
        • et al.
        Electrocardiographic preexcitation and risk of cardiovascular morbidity and mortality: results from the Copenhagen ECG Study.
        Circ Arrhythm Electrophysiol. 2017; 10e004778
        • Rasmussen P.V.
        • Nielsen J.B.
        • Pietersen A.
        • et al.
        Electrocardiographic precordial ST-segment deviations and the risk of cardiovascular death: results from the Copenhagen ECG Study.
        J Am Heart Assoc. 2014; 3e000549
      1. Marquette™ 12SL™. ECG Analysis Program Physician’s Guide 2056246-002 Revision C: General Electric Company; 2019. https://www.gehealthcare.com/products/diagnostic-cardiology/marquette-12sl.

        • Rasmussen P.V.
        • Skov M.W.
        • Ghouse J.
        • et al.
        Clinical implications of electrocardiographic bundle branch block in primary care.
        Heart. 2019; 105: 1160-1167
        • Mason J.W.
        • Ramseth D.J.
        • Chanter D.O.
        • Moon T.E.
        • Goodman D.B.
        • Mendzelevski B.
        Electrocardiographic reference ranges derived from 79,743 ambulatory subjects.
        J Electrocardiol. 2007; 40: 228-234
        • Hancock E.W.
        • Deal B.J.
        • Mirvis D.M.
        • et al.
        AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology.
        Circulation. 2009; 119: e251-e261
        • Rasmussen P.V.
        • Nielsen J.B.
        • Skov M.W.
        • et al.
        Electrocardiographic PR interval duration and cardiovascular risk: results from the Copenhagen ECG Study.
        Can J Cardiol. 2017; 33: 674-681
        • Olesen J.B.
        • Lip G.Y.
        • Hansen M.L.
        • et al.
        Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study.
        BMJ. 2011; 342: d124
        • Kumler T.
        • Gislason G.H.
        • Kirk V.
        • et al.
        Accuracy of a heart failure diagnosis in administrative registers.
        Eur J Heart Fail. 2008; 10: 658-660
        • World Health Organization
        International Statistical Classification of Diseases and Related Health Problems. 10th Revision, Fifth Edition, 2016 Ed.
        World Health Organization, Geneva2015
        • Thygesen S.K.
        • Christiansen C.F.
        • Christensen S.
        • Lash T.L.
        • Sorensen H.T.
        The predictive value of ICD-10 diagnostic coding used to assess Charlson comorbidity index conditions in the population-based Danish National Registry of Patients.
        BMC Med Res Methodol. 2011; 11: 83
        • Ruwald M.H.
        • Hansen M.L.
        • Lamberts M.
        • et al.
        Accuracy of the ICD-10 discharge diagnosis for syncope.
        Europace. 2012; 15: 595-600
        • Monin J.
        • Bisconte S.
        • Nicaise A.
        • Hornez A.-P.
        • Manen O.
        • Perrier E.
        Prevalence of intraventricular conduction disturbances in a large French population.
        Ann Noninvasive Electrocardiol. 2016; 21: 479-485
        • Elizari M.V.
        • Acunzo R.S.
        • Ferreiro M.
        Hemiblocks revisited.
        Circulation. 2007; 115: 1154-1163
        • Lévy S.
        Bundle branch blocks and/or hemiblocks complicating acute myocardial ischemia or infarction.
        J Interv Card Electrophysiol. 2018; 52: 287-292
        • Rotman M.
        • Triebwasser J.H.
        A clinical and follow-up study of right and left bundle branch block.
        Circulation. 1975; 51: 477-484
        • Zoob M.
        • Smith K.S.
        The aetiology of complete heart-block.
        Br Med J. 1963; 2: 1149-1153
        • Khurshid S.
        • Choi S.H.
        • Weng L.-C.
        • et al.
        Frequency of cardiac rhythm abnormalities in a half million adults.
        Circ Arrhythm Electrophysiol. 2018; 11 (e006273)
        • Lenegre J.
        Etiology and pathology of bilateral bundle branch block in relation to complete heart block.
        Prog Cardiovasc Dis. 1964; 6: 409-444
        • Lev M.
        The pathology of complete atrioventricular block.
        Prog Cardiovasc Dis. 1964; 6: 317-326
        • Calò L.
        • Della Bona R.
        • Martino A.
        • et al.
        Left posterior fascicular block and increased risk of sudden cardiac death in young people.
        J Am Coll Cardiol. 2021; 77: 1143-1145
        • McAnulty J.H.
        • Rahimtoola S.H.
        • Murphy E.
        • et al.
        Natural history of "high-risk" bundle-branch block: final report of a prospective study.
        N Engl J Med. 1982; 307: 137-143
        • Moulki N.
        • Kealhofer J.V.
        • Benditt D.G.
        • et al.
        Association of cardiac implantable electronic devices with survival in bifascicular block and prolonged PR interval on electrocardiogram.
        J Interv Card Electrophysiol. 2018; 52: 335-341
        • Santini M.
        • Castro A.
        • Giada F.
        • et al.
        Prevention of syncope through permanent cardiac pacing in patients with bifascicular block and syncope of unexplained origin: the PRESS study.
        Circ Arrhythm Electrophysiol. 2013; 6: 101-107