Left Anterior Fascicular

Block (LAFB)
John Larkin and Robert Buttner ●
Feb 7, 2021

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ECG criteria

Left axis deviation (usually -45 to -90

degrees)
qR complexes in leads I, aVL
rS complexes in leads II, III, aVF
Prolonged R wave peak time in aVL >
45ms

aVR

The

Scroll to annotate: Left Anterior Fascicular Block

(LAFB)

Typical ECG of LAFB, demonstrating:

rS complexes in leads II, III, aVF, with small R

waves and deep S waves
qR complexes in leads I, aVL, with small Q
waves and tall R waves
Left Axis Deviation (LAD): Leads II, III and aVF
are NEGATIVE; Leads I and aVL are POSITIVE

Associated features include:

QRS duration normal or slightly prolonged (80-

110ms)
Increased QRS voltage in limb leads

Electrophysiology

In LAFB, impulses are conducted to the left

ventricle (LV) via the posterior fascicle, which
inserts into the inferoseptal wall of the LV along its
endocardial surface

Depolarisation spreads from endocardium to

epicardium and thus the initial vector is
directed downwards and rightwards, towards
inferior leads. This produces small R waves in
leads II, III and aVF, and small Q waves in leads
I and aVL
The major wave of depolarisation is slightly
delayed and spreads upwards and leftwards,
producing tall R waves in left-sided leads and
deep S waves in inferior leads
This overall delay of approximately 20ms
(compared with normal simultaneous
conduction via both fascicles) results in a
slight widening of the QRS
Because impulses reach the left-sided leads
later than normal, there is an increase R wave
peak time in aVL (time from onset of QRS to
peak of R wave)

,
aVR JU aVl

LeadI

V6
V5

VIl

LeadIll LeadIl

aVF

Sequence of conduction in LAFB

1. YELLOW line: Impulses are conducted to the

left ventricle via the posterior fascicle
2. RED arrow: Initial depolarisation vector is
directed towards inferior leads
3. BLUE arrow : Major depolarisation vector,
which is slightly delayed, is directed towards
left-sided leads

ECG Morphology

aVR

AVI

AVE

Is

qR complexes

qR complexes in lateral limb leads, and rS

complexes in inferior leads

Left Axis Deviation (LAD)

Left Axis Deviation (LAD)

Leads I and aVL are POSITIVE;

Leads II, III and aVF are NEGATIVE

Prolonged R-wave peak time

Prolonged R-wave peak time

Prolonged R-wave peak time (= the time from

onset of the QRS to the peak of the R wave) in
aVL > 45 ms

Examples of LAFB

Example 1

Left axis deviation

qR complexes in I, aVL
rS complexes in II, III, aVF
Prolonged R wave peak time in aVL
Increased QRS voltage in limb leads

Example 2

Left axis deviation

qR complexes in I, aVL; rS complexes in inferior
leads
Prolonged R wave peak time in aVL
Slightly prolonged QRS duration

Example 3

Handy Tips

In LAFB, the QRS voltage in lead aVL

may meet voltage criteria for LVH (R
wave height > 11 mm), but there will
be no LV strain pattern.

Related Topics
Left bundle branch block LBBB
Right Bundle Branch Block RBBB
Left anterior fascicular block LAFB
Left posterior fascicular block LPFB
Interventricular Conduction Delay IVCD
Bifascicular block
Trifascicular block
Complete Heart block CHB

Advanced Reading

Online

Wiesbauer F, Kühn P. ECG Yellow Belt online

course: Become an ECG expert. Medmastery
Wiesbauer F, Kühn P. ECG Blue Belt online
course: Learn to diagnose any rhythm problem.
Medmastery
Rawshani A. Clinical ECG Interpretation ECG
Waves
Smith SW. Dr Smith’s ECG blog.

Textbooks

Mattu A, Tabas JA, Brady WJ.

Electrocardiography in Emergency, Acute, and
Critical Care. 2e, 2019
Brady WJ, Lipinski MJ et al. Electrocardiogram
in Clinical Medicine. 1e, 2020
Straus DG, Schocken DD. Marriott’s Practical
Electrocardiography 13e, 2021
Hampton J. The ECG Made Practical 7e, 2019
Grauer K. ECG Pocket Brain (Expanded) 6e,
2014
Brady WJ, Truwit JD. Critical Decisions in
Emergency and Acute Care
Electrocardiography 1e, 2009
Surawicz B, Knilans T. Chou’s
Electrocardiography in Clinical Practice: Adult
and Pediatric 6e, 2008
Mattu A, Brady W. ECG’s for the Emergency
Physician Part I 1e, 2003 and Part II
Chan TC. ECG in Emergency Medicine and
Acute Care 1e, 2004
Smith SW. The ECG in Acute MI. 2002 [PDF]

LITFL Further Reading

ECG Library Basics – Waves, Intervals,
Segments and Clinical Interpretation
ECG A to Z by diagnosis – ECG interpretation
in clinical context
ECG Exigency and Cardiovascular Curveball –
ECG Clinical Cases
100 ECG Quiz – Self-assessment tool for
examination practice
ECG Reference SITES and BOOKS – the best
of the rest

ECG LIBRARY
Electrocardiogram

EKG Library

John Larkin

Emergency Medicine Specialist MBChB FRCEM

FACEM. Medical Education, Cardiology and
Web Based Resources | @jjlarkin78 | LinkedIn |

Robert Buttner

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST,

AAA) Adult/Paediatric Emergency Medicine
Advanced Trainee in Melbourne, Australia.
Special interests in diagnostic and procedural
ultrasound, medical education, and ECG
interpretation. Editor-in-chief of the LITFL ECG
Library. Twitter: @rob_buttner

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