ABSTRACT Rationale: Left bundle branch block and hypertensive emergency are very common conditions in clinical cardiovascular and emergency practice. Hypertensive emergency encompasses a spectrum of clinical presentations in which uncontrolled blood pressure leads to progressive end-organ dysfunction. Suspected acute myocardial infarction in the setting of a left bundle branch block presents a unique diagnostic and therapeutic challenge to the clinician. The diagnosis is especially difficult due to electrocardiographic changes caused by altered ventricular depolarization. However, reports on the use of Sgarbossa’s criteria in the management of hypertensive emergencies are rare. Patient concerns: A middle-aged married heavy-smoker Egyptian male worker presented to the emergency department with a hypertensive emergency patient with acute chest pain and left bundle branch block. Sgarbossa’s criteria were initially very weak and, over time, became highly suggestive of acute ST-segment elevation myocardial infarction. Interestingly, chest pain increased as Sgarbossa’s diagnostic criteria were met. Thrombolytic therapy was strongly indicated because of a higher development of Sgarbossa criteria scoring. Intervention; Electrocardiography, oxygenation, streptokinase IVI, and echocardiography Diagnosis: Developing acute ST-segment elevation myocardial infarction in the presence of left bundle branch block post hypertensive emergency. Outcomes: The dramatic response to developing acute myocardial infarction in the left bundle branch block with hypertensive emergency to streptokinase. Lessons: The higher Sgarbossa criteria scoring in the case was the only indication for thrombolytic. Therefore, how did Sgarbossa's criteria develop during case management to indicate the need for thrombolytic therapy?

6. . The researcher will be lucky if the case report will be
including complex data.
. Sometimes, the case report takes multiple directions
in understanding.
. The physician should be a strong observer of the new
clinical findings.

8. Rationale: Left bundle branch block and hypertensive emergency are very common conditions in clinical cardiovascular and
emergency practice. Hypertensive emergency encompasses a spectrum of clinical presentations in which uncontrolled blood
pressure leads to progressive end-organ dysfunction. Suspected acute myocardial infarction in the setting of a left bundle branch
block presents a unique diagnostic and therapeutic challenge to the clinician. The diagnosis is especially difficult due to
electrocardiographic changes caused by altered ventricular depolarization. However, reports on the use of Sgarbossa’s criteria in
the management of hypertensive emergency is rare.
Patient concerns: A middle-aged married heavy-smoker Egyptian male worker presented to the emergency department with a
hypertensive emergency patient with acute chest pain and left bundle branch block. Sgarbossa’s criteria were initially very weak
and, over time, became highly suggestive of acute ST-segment elevation myocardial infarction. Interestingly, chest pain increased
as Sgarbossa’s diagnostic criteria were met. Thrombolytic therapy was strongly indicated because of a higher development of
Sgarbossa criteria scoring.
Intervention; Electrocardiography, oxygenation, streptokinase IVI, and echocardiography.
Diagnosis: Developing acute ST-segment elevation myocardial infarction in the presence of left bundle branch block post-
hypertensive emergency.
Outcomes: The dramatic response to developing acute myocardial infarction in left bundle branch block with hypertensive
emergency to streptokinase.
Lessons: The higher Sgarbossa criteria scoring in the case was the only indication for thrombolytic. Therefore, how did Sgarbossa
criteria develop during case management to indicate the need for thrombolytic therapy?

10. . Left bundle branch block.
. Sgarbossa criteria and its modification.
. Hypertensive emergency.
. ST-segment elevation myocardial infarction.
. The decision of thrombolytic in left bundle
branch block.

11. Discovery history

12. . Heavy-smoker Egyptian male.
. Acute anginal chest pain.
. Hypertensive crises.
. ECG left bundle branch block.
. New progressive ST-segment elevation.

13. Identification of keys
of the case

14. 1. Left bundle branch block and ST-segment elevation
myocardial infarction
• Diagnosis of ST-segment elevation myocardial infarction (STEMI) in the
setting of a left bundle branch block (LBBB) is difficult.
• Timely and accurate identification of acute coronary occlusion in the setting
of ischemic symptoms is critical to initiating urgent angiography and
appropriate reperfusion therapy.
• ST elevation on the ECG is the primary indication for emergency reperfusion
therapy.
• However, identification of STEMI in the setting of left bundle branch block
remains challenging.
• LBBB is a major ECG confounder for STEMI diagnosis using ECG.

15. 2. Sgarbossa criteria and its modification
• Sgarbossa et al. introduced ECG criteria for detecting STEMI in the presence of LBBB.
• The criteria are based on concordant ST-segment elevation, discordant ST elevation and
anterior ST depression in leads V1-V3, with points assigned for each criterion.
• In several studies, the discordant ST-segment elevation criterion has been shown to be less
useful than the other two criteria to maintain a high specificity.
• The best threshold for the Sgarbossa score is greater than or equal to 3.
• A score of three or greater generated from the Sgarbossa criteria has been commonly used
by researchers. Sgarbossa et al proposed requiring at least 3 points from the following
criteria for the diagnosis of acute myocardial infarction in the presence of left bundle
branch block: (1) concordant ST-segment elevation of 1 mm (0.1 mV) in at least 1 lead (5
points), (2) concordant ST-segment depression of at least 1 mm in leads

16. V1 to V3 (3 points), or (3) excessively discordant ST-segment elevation, defined
as greater than or equal to 5 mm of ST-segment elevation when the QRS result
is negative (2 points) (Table 1).
Table 1: Sgarbossa criteria scoring and its modification.
Criteria Description Score points
Sgarbossa A Concordant ST elevation > 1mm (0.1 mV) in at
least 1 lead, in leads with positive QRS
5
Sgarbossa B Concordant ST depression ≥ 1mm in V1 - V3 3
Sgarbossa C Discordant ST elevation ≥ 5mm , in leads with
negative QRS
2
Modified Sgarbossa C
(Smith critreia)
Discordant ST elevation and ST/S ratio ≤ 0.25 Modified Sgarbossa criteria: superior to
original Sgarbossa criteria
For Dx ACO in LBBB
Dx ; diagnosing , ACO; acute coronary occlusion, LBBB; left bundle branch block

17. 3. Hypertensive emergency
• Hypertensive crises (76% urgencies and 24% emergencies) represented 3%
of all the patient visits, but 27% of all medical emergencies.
• Hypertensive crisis is defined as levels of systolic blood pressure >180 mmHg
and/or levels of diastolic blood pressure >120 mmHg.
• Depending on whether there is damage to vital organs or not, we can
distinguish between hypertensive emergency and hypertensive urgency.
Hypertensive emergencies are life-threatening conditions because their
outcome is complicated by acute damage to vital organs, and can be presented
with neurological, renal, cardiovascular, microangiopathic and obstetric
complications. Hypertensive emergencies include hypertensive encephalopathy,
hypertensive acute left ventricular relaxation associated with acute

18. myocardial infarction or unstable angina, aortic dissection,
subarhnoic hemorrhage, ischemic stroke, and severe pre-eclampsia
or eclampsia6.
• Hypertensive emergencies occur in up to 2% of patients with
systemic hypertension.
• The most common symptoms are headache, dyspnea, nausea,
vomiting, epistaxis, and pronounced anxiety.
• Immediate reduction in blood pressure is required only in patients
with acute endorgan damage.
• Nitroglycerin as a potent venodilator reduces BP, decreasing
preload and cardiac output Therefore, it is not an acceptable first
choice for hypertensive emergencies except in patients with acute
coronary ischemia.

19. 5. The decision of thrombolytic in LBBB
• The decision of receiving thrombolytic in LBBB
is depending on the Sgarbossa criteria scoring
• The presence of acute ischemic chest pain share
in this decision
• A new or old LBBB is cornerstone.

20. Case presentation

21. 1. Complaint and History
• A 53 year-old married heavy-smoker Egyptian male worker patient presented to the ED
with acute chest pain, palpitations, rapid breathing, and dizziness
• Patient had recent history of psycho-familial troubles.
• Chest pain had anginal characteristics.
• There was past history of hypertension on chest pain furosemide tablet (40 mg once
daily), and captopril tablet (25 mg twice daily).
• The patient denied a history of cardiac or other relevant diseases.

22. 2. Physical examination
• Generally; the patient appeared irritable, sweaty, anxious,
and tachypneic.
• Vital signs; blood pressure of 240/140 mmHg, the pulse rate
of 100/bpm; and regular, the respiratory rate of 36/min, the
temperature of 36.2°C, and the pulse oximeter of oxygen
(O2) saturation of 92%.
• Otherwise of tachypnia, dyspnea, and tachycardia, there no
local cardio-respiratory signs were noted during the clinical
examination.

23. Figure 1A: ECG tracing of presentation in the ED showing sinus tachycardia (VR;180 bpm) with LBBB.
Red arrows; indicate Sgarbossa criteria with discordant ST elevation > 5mm (V2-4). Both blue and black
arrows; indicate no other ST-segment abnormalities.

24. Figure 2B-D serial ECG: 2B. ECG tracing: the initial ECG tracing in ICU was done within 12 minutes of ED ECG tracing
showing no more difference than 1A. 2C. ECG tracing showing concordant ST elevation > 5mm in high lateral leads (I,
aVL) (=blue arrows) with ST-segment depression in inferior leads (II, III, aVF) (=black arrows). 2D. ECG tracing was taken
within five hours of first ECG tracing and within two hours of streptokinase showing the same 1A. ECG tracing.

25. B. Troponin test
• The troponin test was positive.
C. RBS
• Measured random blood sugar was 223 mg/dl.
D. Echocardiography
• Later echocardiography showed antro-lateral hypokinesia with EF 63%.
E. No more workup
• No more workup was done.

26. The most probable diagnosis
• Developing acute ST-segment
elevation myocardial infarction in the
presence of left bundle branch block
post-hypertensive emergency.

28. • Patient was admitted to ICU as a hypertensive emergency with angina and
LBBB.
• He was initially managed with O2 inhalation using nasal cannula in rate of 5
L/min, sublingual isosorbide dinitrate tablet (4 mg), and sublingual captopril
tablet (25 mg) were given.
• The initial ECG tracing was taken in the ED; that showed sinus tachycardia
(VR;180 bpm) with LBBB (Figure 1A).
• The only taken score of initial Sgarbossa criteria was (2) with discordant ST
elevation > 5mm.
• Nitroglycerin IVI (5 µg/min with intermittent titration) was maintained.

29. • Serial ECG tracings were taken. No significant change within 12 minutes of
first ECG tracing (Figure 2B). ST-segment elevation myocardial infarction
appeared in high lateral leads (I, aVL) with ST-segment depression in inferior
leads (II, III, aVF) (Figure 2C). Sgarbossa criteria reached to score (7).
• Blood pressure was controlled within three hours of admission (140/85
mmHg). Aspirin 4 oral tablet (75 mg), clopidogril 4 oral tablet (75 mg),
streptokinase IVI (1.5 million units over 60 minutes) were added.
• ECG tracing was taken within five hours of first ECG tracing and within
two hours of streptokinase infusion. Sgarbossa criteria return to the initial
score that was (2) (Figure 2D).

30. • Patient became symptomatic free after streptokinase infusion and controlling
blood pressure.
• Patient was continued on; captopril tablet (25 mg twice daily), aspirin tablet
(75 mg, once daily), clopidogril tablet (75 mg, once daily), nitroglycerin
retard capsule (2.5 mg twice daily), and atorvastatin (40 mg once daily) until
discharged on the 5th day.

32. • Overview: A middle-aged married heavy-smoker Egyptian male worker
presented to the emergency department with a hypertensive emergency
patient with acute chest pain and left bundle branch block.
• The primary objective for the current case study was the presence of
angina, sinus tachycardia, hypertensive emergency, and LBBB.
• The secondary objective for the case study was the priority in the
management of angina, sinus tachycardia, hypertensive emergency, and
LBBB. And how would you manage the case in the ICU?
• LBBB is a common problem in our clinical practice but an extremely rare to
see LBBB given STEMI with developement of Sgarbossa criteria.

33. • The only initial criteria for Sgarbossa was discordant ST elevation > 5mm
(score 2) which very low (Figure 1, and Figure 2A). This only initial taken
score of Sgarbossa criteria indicated that there was no seriousness.
• Appearance of concordant ST elevation > 1mm in leads with positive QRS
(I, aVL) but with reciprocal ST depression in inferior leads (II, III, aVF)
indicates ST-segment elevation myocardial infarction appeared in high lateral
leads rather the extensive anterior STEMI.
• Return of LBBB to basic initial Sgarbossa criteria (Figure 2D) after
streptokinase infusion and controlling blood pressure.

35. • The current case was LBBB with subsequently
developed acute ST-segment elevation myocardial
infarction that was indicating for thrombolytic
therapy.
• Both hypertensive emergency and ECG LBBB
pattern were encompassing the serious consequences in
the case.
• Serial ECG tracings were showing a graded
developing of Sgarbossa criteria of LBBB that is
meeting with the diagnosis of acute myocardial
infarction.

36. • Upgrading of Sgarbossa criteria of LBBB had happened throughout the
course of the hypertensive emergency.
• Presence of LBBB, angina, positive troponin, and Sgarbossa score of 7 were
indications for the presence of acute ST-segment elevation myocardial
infarction.
• The only initial electrocardiographic Sgarbossa criteria were discordant ST
elevation > 5mm (score 2). This lonely ECG sign is an insufficient indication
for a more serious condition.
• concordant ST elevation > 1mm in leads (I, aVL) with reciprocal ST
depression in inferior leads (II, III, aVF) are specified for a high lateral ST-
segment elevation myocardial infarction rather than the extensive anterior
infarction.
• Resolving of developed Sgarbossa criteria in LBBB to the initial condition
after streptokinase infusion and controlling of blood pressure had occurred.

37. • The novelty in the case study was the marvelous progression of the LBBB to
the acute infarction that is an indication for thrombolytic therapy.
• Unfortunately, there were similar cases for comparison in the past literature.

38. Acknowledgment
•I wish to thank Ahmed Alghobary, B.sc. for his
technical support.

39. Conclusion and Recommendations

40. • Resolving of upgrading of Sgarbossa criteria in LBBB to the initial status
after streptokinase infusion with controlling of blood pressure will strengthens
the role of streptokinase and tight blood pressure control.
• The current case is considered the first reported case study where up-grading
of Sgarbossa criteria for LBBB into acute ST-segment elevation myocardial
infarction during the course of hypertensive emergency had happened.
• Moreover, this case report highlights the importance of adequate and tight
controlling for patients of hypertensive emergency with LBBB.

41. References

42. 1 Stephen W. Smith, Kenneth W. Dodd, Timothy D. Henry, David M. Dvorak, Lesly A. Pearce. Diagnosis of ST-
Elevation Myocardial Infarction in the Presence of Left Bundle Branch Block With the ST-Elevation to S-Wave Ratio in
a Modified Sgarbossa Rule. Ann Emerg Med. 2012;60:766-776.
2 Richard E Gregg, Eric D Helfenbein, Sophia H Zhou. Combining Sgarbossa and Selvester ECG Criteria to Improve
STEMI Detection in the Presence of LBBB. Computing in Cardiology 2010;37:277−280. ISSN 0276−6574
3 Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial
infarction in the presence of left bundle branch block. N Engl J Med. 1996;334:481-487.
4 Meyers HP III, Limkakeng AT, Jr., Jaffa EJ, Patel A, Theiling BJ, Rezaie SR, Steward T, Zhuang C, Pera VK, Smith SW.
Validation of the Modified Sgarbossa Criteria for Acute Coronary Occlusion in the Setting of Left Bundle Branch
Block: Retrospective Case Control Study. Annals of Emergency Medicine. 2015 Oct.; (66) 4S:S17.
5 Joseph Varon and Paul E Marik. Clinical review: The management of hypertensive crises. Critical Care. 2003;7:374-
384. DOI 10.1186/cc2351
6 Sabina Salkic, Olivera Batic-Mujanovic, Farid Ljuca, Selmira Brkic. Clinical Presentation of Hypertensive Crises in
Emergency Medical Services. Mater Sociomed. 2014 Feb; 26(1): 12-16. DOI: 10.5455/msm.2014.26.12-16
7 Paul E. Marik and Racquel Rivera.Hypertensive emergencies: an update. Curr Opin Crit Care. 17:569–580.
DOI:10.1097/MCC.0b013e32834cd31d
8 Norman M. Kaplan, Ronald G. Victor, Joseph T. Flynn. Chapter 8;Hypertensive Emergencies. Kaplan’s Clinical
Hypertension. Eleventh edit. 2015;269-272. 2015 Wolters Kluwer. ISBN 978-1-4511-9013-7.