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A different look at the conventional 12-lead electrocardiogram
Correspondence / American Journal of Emergency Medicine 33 (2015) 1093–1107 [9] Weaver C, Schiech L, Held-Warmkessel J, Kedziera P, Haney E, DiLullo G, et al. Risk for unplanned hospital readmission of patients with cancer: results of a retrospective medical record review. Oncol Nurs Forum 2006;33:E44–52. [10] Hewitt M, Simone J. Ensuring quality cancer care. Washington, DC: National Academies Press; 1999. [11] Donat SM, Shabsigh A, Savage C, Cronin AM, Bochner BH, Dalbagni G, et al. Potential impact of postoperative early complications on the timing of adjuvant chemotherapy in patients undergoing radical cystectomy: a high-volume tertiary cancer center experience. Eur Urol 2009;55:177–85. [12] Greenblatt DY, Weber SM, O'Connor ES, LoConte NK, Liou JI, Smith MA, et al. Readmission after colectomy for cancer predicts one-year mortality. Ann Surg 2010; 251:659–69. [13] Eley KA, Shah R, Bond SE, Watt-Smith SR. A review of post-operative feeding in patients undergoing resection and reconstruction for oral malignancy and presentation of a pre-operative scoring system. Br J Oral Maxillofac Surg 2012;50: 601–5. [14] O'Neill JP, Shaha AR. Nutrition management of patients with malignancies of the head and neck. Surg Clin North Am 2011;91:631–9.
A different look at the conventional 12-lead electrocardiogram To the Editor, We report the usefulness of a new approach in evaluating the 12lead electrocardiogram (ECG) in patients suspected of having an acute coronary syndrome. We wish to highlight the diagnostic significance of ST-segment changes in some of the unique reciprocal leads in the setting of acute coronary syndrome. The initial ECG manifestation of acute transural myocardial ischemia is ST-segment elevation in the leads facing the ischemic zone and STsegment depression in the leads facing the anatomically opposite myocardial segments [1]. To increase specificity for diagnosing an STelevation myocardial infarction (STEMI), ST elevation above the threshold should be seen in at least 2 adjacent ECG leads [2]. In a conventional 12-lead ECG, there are 3 contiguous pairs in limb leads aVL and I, II and aVF, and aVF and III and 5 contiguous pairs in precordial leads V1 and V2, V2 and V3, V3 and V4, V4 and V5, and V5 and V6 [3,4]. Some of the early ECG changes of acute myocardial infarction (MI) can be subtle. Acute transmural MI may occur in patients with ST elevation less than the accepted thresholds or only ST elevation in 1 lead. This may sometimes be the case with small QRS complexes in the affected leads, especially limb leads or leads that do not have contiguous leads like aVL, III, and aVR. Identification of contiguity is obvious among the 6 standard transverse plane leads but is challenging for limb leads. The 24-lead
Fig. 1. Leads aVL, I, II, III, and aVR with their counterparts leads, lead −aVR fills the gap between leads I and II.
1105
ECG include the standard 12-lead ECG as both the classic positive leads and their inverted counterparts. Using a 24-lead ECG increases the sensitivity with minimal loss of specificity for diagnosing of an acute coronary occlusion, especially when STEMI criteria are not met in the 12-lead ECG [5,6]. In the 24-lead ECG, 2 more contiguous pairs become obvious in the frontal plane: +I and −aVR and −aVR and +II [7]. The −aVR lead fills the gap between leads I and II and provides a comprehensive view of the frontal plane (Fig. 1). When significant ST elevation occurs at the end of an arc, such as only in lead + III or only in lead + aVL, using a lead pair such as –aVL and –III helps establish STEMI criteria for the diagnosis of inferolateral or superolateral infarctions [8]. The application of a 24-leads ECG is not routinely feasible in emergency department. Instead of using a 24-lead ECG, counterpart leads in a 12-lead ECG can give us part of this information [9]. Opposite direction ST-segment changes of reciprocal leads are equivalent to ST elevation of 2 contiguous leads in a 24-lead ECG. Positive poles of pair leads of aVl and III, aVR and I, and aVR and II oriented 150° apart are truly reciprocal in a 12-lead ECG (Fig. 2). Reciprocal changes of ST elevation in lead aVL secondary to an acute anterior MI present as ST depression in lead III. Reciprocal changes of ST elevation of lead III secondary to an acute inferior MI present as a ST depression in lead aVL [6,10-14]. Because the ST-segment vector in lead aVL is relatively opposite to the ST-segment vector in leads III and aVF, inferior ST depression in an acute anterior wall MI is merely reciprocal changes and predicts a complicated clinical course [15]. Both dominant left circumflex and right coronary artery occlusion usually result in ST elevation in the inferior leads. The finding of a reciprocal ST depression in lead aVL and ST elevation in lead III can be the only early ECG changes in these patients [16]. The lead vector of aVR is orientated from the cardiac apex to the outflow tract of the right ventricle. Transmural myocardial ischemia of the basal segment of the interventricular septum can produce an ST elevation in aVR secondary to the positive direction of injury current dipole has a component in the direction of the lead vector of aVR. At the same time, this injury current may induce an ST depression in leads I and II. Leads I and II are reciprocal to aVR, and their vector direction is opposite to that of the aVR vector pole. Likewise, a transmural apical infarction can produce an ST depression in lead aVR and ST elevation in lead I [17,18]. Studies have shown that, in an inferior STEMI, ST-segment depression in lead aVR is more common in a left circumflex occlusion than in a right coronary artery occlusion [17,19-22]. There is accumulating evidence that ST-segment changes from unique reciprocal leads of a 12-lead ECG may give us more information. These ECG changes may help increase the early diagnostic
Fig. 2. Leads aVl and III, aVR and I, and aVR and II oriented 150° apart are truly reciprocal in a 12-lead ECG.
1106
Correspondence / American Journal of Emergency Medicine 33 (2015) 1093–1107
accuracy and optimal treatment of subtle changes that may be indicate of a myocardial infarction that could be otherwise missed. Physician training should emphasize the importance and significance of these changes.
Soheila Talebi, MD Medicine Department, New York Medical College, Metropolitan Hospital Center Valhalla, NY Sameer Chaudhari, MD Cardiology Department, Newark Beth Israel Medical Center, Newark, NJ Hans Reyes, MD Medicine Department, New York Medical College, Metropolitan Hospital Center Valhalla, NY Ferdinand Visco, MD Gerald Pekler, MD Cardiology Department, New York Medical College, Metropolitan Hospital Center Valhalla, NY Getaw Worku Hassen, MD, PhD Emergency Department, New York Medical College, Metropolitan Hospital Center Valhalla, NY Corresponding author at: New York Medical College, Metropolitan Hospital Center, Emergency Department, 1901 1st Ave, New York, NY 10029 Tel.: +1 212 423 6262 E-mail address: [email protected]
[13] Takatsu F, Osugi J, Ozaki Y, Nagaya T. Relationship between abnormal Q waves in lead aVL and angiographic findings—a study to redefine “high lateral” infarction. Jpn Circ J 1988;52(2):169–74. [14] Martin TN, Groenning BA, Murray HM, Steedman T, Foster JE, Elliot AT, et al. ST-segment deviation analysis of the admission 12-lead electrocardiogram as an aid to early diagnosis of acute myocardial infarction with a cardiac magnetic resonance imaging gold standard. J Am Coll Cardiol 2007;50(11): 1021–8. [15] Porter A, Sclarovsky S, Ben-Gal T, Herz I, Solodky A, Sagie A. Value of T-wave direction with lead III ST segment depression in acute anterior wall myocardial infarction: electrocardiographic prediction of a “wrapped” left anterior descending artery. Clin Cardiol 1998;21(8):562–6. [16] Atar S, Barbagelata A, Birnbaum Y. Electrocardiographic diagnosis of ST-elevation myocardial infarction. Cardiol Clin 2006;24:343–65. [17] Nair R, Glancy DL. ECG discrimination between right and left circumflex coronary arterial occlusion in patients with acute inferior myocardial infarction: value of old criteria and use of lead aVR. Chest 2002;122:134–9. [18] Wong CK, Freedman SB. Electrocardiographic identification of the infarctrelated artery in acute inferior myocardial infarction. Int J Cardiol 1996;54: 5–11. [19] Sun TW, Wang LX, Zhang YZ. The value of ECG lead aVR in the differential diagnosis of acute inferior wall myocardial infarction. Intern Med 2007;46: 795–9. [20] Kanei Y, Sharma J, Diwan R, Sklash R, Vales LL, Fox JT, et al. ST-segment depression in aVR as a predictor of culprit artery and infarct size in acute inferior wall ST segment elevation myocardial infarction. J Electrocardiol 2010;43:132–5. [21] Menown IB, Adgey AA. Improving the ECG classification of inferior and lateral myocardial infarction by inversion of lead aVR. Heart 2000;83: 657–60. [22] Kosuge M, Kimura K, Ishikawa T, Ebina T, Hibi K, Toda N, et al. ST-segment depression in lead aVR: a useful predictor of impaired myocardial reperfusion in patients with inferior acute myocardial infarction. Chest 2005;128: 780–6.
http://dx.doi.org/10.1016/j.ajem.2015.04.075 References [1] Fuchs RM, Achuff SC, Grunwald L, Yin FC, Griffith LS. Electrocardiographic Localization of coronary artery narrowings: studies during myocardial ischemia and infarction in patients with one vessel disease. Circulation 1982;66(6): 1168–76. [2] Myocardial infarction redefined: a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction. Eur Heart J 2000;21:1502–13. [3] Anderson ST, Pahlm O, Selvester RH, Bailey JJ, Berson AS, Barold SS, et al. A panoramic display of the orderly sequenced twelve lead electrocardiogram. J Electrocardiol 2004;27:347–52. [4] Brady WJ, Perron AD, Chan T. Electrocardiographic ST-segment elevation: correct identification of acute myocardial infarction (AMI) and non-AMI syndromes by emergency physicians. Acad Emerg Med 2001;8:349–60. [5] Perron A, Lim T, Pahlm-Webb U, Wagner GS, Pahlm O. Maximal increase in sensitivity with minimal loss of specificity for diagnosis of acute coronary occlusion achieved by sequentially adding leads from the 24-lead electrocardiogram to the orderly sequenced 12-lead electrocardiogram. J Electrocardiol 2007;40(6): 463–9. [6] Pahlm U, Pahlm O, Wagner GS. The 24-lead ECG display for enhanced recognition of STEMI equivalent patterns in the 12-lead ECG. J Electrocardiol 2014;47(4): 425–9. [7] Sgarbossa EB, Barold SS, Pinski SL, Wagner GS, Pahlm O. Twelve-lead electrocardiogram: the advantages of an orderly frontal lead display including lead -aVR. J Electrocardiol 2004;37(3):141–7. [8] Shah A, Wagner GS, Green CL, Crater SW, Sawchak ST, Wildermann NM, et al. Electrocardiographic differentiation of the ST segment depression of acute epicardial injury due to left circumflex artery occlusion from that of subendocardial injury due to non-occlusive ischemia. Am J Cardiol 1997;80:512–3. [9] Hasdai D, Yeshurun M, Birnbaum Y, Sclarovsky S. Inferior wall acute myocardial infarction with one lead ST-segment elevation: electrocardiographic distinction between a benign and a malignant clinical course. Coron Artery Dis 1995;6: 875–81. [10] De Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982; 103(4):730–6. [11] Iwasaki K, Kusachi S, Kita T, Taniguchi G. Prediction of isolated first diagonal branch occlusion by 12-lead electrocardiography: ST segment shift in leads I and aVL. J Am Coll Cardiol 1994;23(7):1557–61. [12] Birnbaum Y, Sclarovsky S, Mager A, Strasberg B, Rechavia E. ST segment depression in a VL: a sensitive marker for acute inferior myocardial infarction. Eur Heart J 1993; 14:4–7.
The outcomes of elderly ED patients intubated because of community acquired pneumonia: Why not give noninvasive ventilation a chance? To the Editor, We have read the study regarding the impact of age on outcomes of elderly patients admitted to emergency department (ED) because of severe community acquired pneumonia (CAP) and treated with invasive mechanical ventilation (IMV) by Hifumi et al [1] with great interest. The authors investigated patients older than 65 years who were divided in 3 groups (65-74, 75-84, and 85 years or older). No significant differences were observed among the 3 groups on mechanical ventilation (MV), hospital mortality, ventilator-free days, or intensive care unit (ICU) days. The authors conclude that age, in itself, may not be a factor limiting the initiation of MV in the ED in advanced age with CAP. This conclusion, among other contentions, in Hifumi et al demands some perspective. We provide some observations based on our experience with the treatment of CAP in elderly patients. 1. As previously reported, the proportion of elderly persons among hospitalized patients, including ICU admissions, is rapidly increasing in developed countries: very old patients represent 10% to 15% of ICU admissions [2]. In patients with chronic obstructive pulmonary disease with hypercapnia, noninvasive ventilation (NIV) achieved high rate of success in very old patients, and MV was of questionable value [3]. Did the authors consider in less severely ill patients (as measured by objective parameters) the use of NIV before IMV, which can decrease the need of intubation and ICU mortality [4]? 2. Numerous previous studies have suggested that age alone is not a reliable predictor of mortality in the critically ill patients. Other predictors including disease severity using objective criteria, body mass index, functional impairment, or the presence of an underlying fatal disease account for poor outcomes in elderly cohorts [5]. It would be of great interest to know if the authors considered illness severity
A different look at the conventional 12-lead electrocardiogram To the Editor, We report the usefulness of a new approach in evaluating the 12lead electrocardiogram (ECG) in patients suspected of having an acute coronary syndrome. We wish to highlight the diagnostic significance of ST-segment changes in some of the unique reciprocal leads in the setting of acute coronary syndrome. The initial ECG manifestation of acute transural myocardial ischemia is ST-segment elevation in the leads facing the ischemic zone and STsegment depression in the leads facing the anatomically opposite myocardial segments [1]. To increase specificity for diagnosing an STelevation myocardial infarction (STEMI), ST elevation above the threshold should be seen in at least 2 adjacent ECG leads [2]. In a conventional 12-lead ECG, there are 3 contiguous pairs in limb leads aVL and I, II and aVF, and aVF and III and 5 contiguous pairs in precordial leads V1 and V2, V2 and V3, V3 and V4, V4 and V5, and V5 and V6 [3,4]. Some of the early ECG changes of acute myocardial infarction (MI) can be subtle. Acute transmural MI may occur in patients with ST elevation less than the accepted thresholds or only ST elevation in 1 lead. This may sometimes be the case with small QRS complexes in the affected leads, especially limb leads or leads that do not have contiguous leads like aVL, III, and aVR. Identification of contiguity is obvious among the 6 standard transverse plane leads but is challenging for limb leads. The 24-lead
Fig. 1. Leads aVL, I, II, III, and aVR with their counterparts leads, lead −aVR fills the gap between leads I and II.
1105
ECG include the standard 12-lead ECG as both the classic positive leads and their inverted counterparts. Using a 24-lead ECG increases the sensitivity with minimal loss of specificity for diagnosing of an acute coronary occlusion, especially when STEMI criteria are not met in the 12-lead ECG [5,6]. In the 24-lead ECG, 2 more contiguous pairs become obvious in the frontal plane: +I and −aVR and −aVR and +II [7]. The −aVR lead fills the gap between leads I and II and provides a comprehensive view of the frontal plane (Fig. 1). When significant ST elevation occurs at the end of an arc, such as only in lead + III or only in lead + aVL, using a lead pair such as –aVL and –III helps establish STEMI criteria for the diagnosis of inferolateral or superolateral infarctions [8]. The application of a 24-leads ECG is not routinely feasible in emergency department. Instead of using a 24-lead ECG, counterpart leads in a 12-lead ECG can give us part of this information [9]. Opposite direction ST-segment changes of reciprocal leads are equivalent to ST elevation of 2 contiguous leads in a 24-lead ECG. Positive poles of pair leads of aVl and III, aVR and I, and aVR and II oriented 150° apart are truly reciprocal in a 12-lead ECG (Fig. 2). Reciprocal changes of ST elevation in lead aVL secondary to an acute anterior MI present as ST depression in lead III. Reciprocal changes of ST elevation of lead III secondary to an acute inferior MI present as a ST depression in lead aVL [6,10-14]. Because the ST-segment vector in lead aVL is relatively opposite to the ST-segment vector in leads III and aVF, inferior ST depression in an acute anterior wall MI is merely reciprocal changes and predicts a complicated clinical course [15]. Both dominant left circumflex and right coronary artery occlusion usually result in ST elevation in the inferior leads. The finding of a reciprocal ST depression in lead aVL and ST elevation in lead III can be the only early ECG changes in these patients [16]. The lead vector of aVR is orientated from the cardiac apex to the outflow tract of the right ventricle. Transmural myocardial ischemia of the basal segment of the interventricular septum can produce an ST elevation in aVR secondary to the positive direction of injury current dipole has a component in the direction of the lead vector of aVR. At the same time, this injury current may induce an ST depression in leads I and II. Leads I and II are reciprocal to aVR, and their vector direction is opposite to that of the aVR vector pole. Likewise, a transmural apical infarction can produce an ST depression in lead aVR and ST elevation in lead I [17,18]. Studies have shown that, in an inferior STEMI, ST-segment depression in lead aVR is more common in a left circumflex occlusion than in a right coronary artery occlusion [17,19-22]. There is accumulating evidence that ST-segment changes from unique reciprocal leads of a 12-lead ECG may give us more information. These ECG changes may help increase the early diagnostic
Fig. 2. Leads aVl and III, aVR and I, and aVR and II oriented 150° apart are truly reciprocal in a 12-lead ECG.
1106
Correspondence / American Journal of Emergency Medicine 33 (2015) 1093–1107
accuracy and optimal treatment of subtle changes that may be indicate of a myocardial infarction that could be otherwise missed. Physician training should emphasize the importance and significance of these changes.
Soheila Talebi, MD Medicine Department, New York Medical College, Metropolitan Hospital Center Valhalla, NY Sameer Chaudhari, MD Cardiology Department, Newark Beth Israel Medical Center, Newark, NJ Hans Reyes, MD Medicine Department, New York Medical College, Metropolitan Hospital Center Valhalla, NY Ferdinand Visco, MD Gerald Pekler, MD Cardiology Department, New York Medical College, Metropolitan Hospital Center Valhalla, NY Getaw Worku Hassen, MD, PhD Emergency Department, New York Medical College, Metropolitan Hospital Center Valhalla, NY Corresponding author at: New York Medical College, Metropolitan Hospital Center, Emergency Department, 1901 1st Ave, New York, NY 10029 Tel.: +1 212 423 6262 E-mail address: [email protected]
[13] Takatsu F, Osugi J, Ozaki Y, Nagaya T. Relationship between abnormal Q waves in lead aVL and angiographic findings—a study to redefine “high lateral” infarction. Jpn Circ J 1988;52(2):169–74. [14] Martin TN, Groenning BA, Murray HM, Steedman T, Foster JE, Elliot AT, et al. ST-segment deviation analysis of the admission 12-lead electrocardiogram as an aid to early diagnosis of acute myocardial infarction with a cardiac magnetic resonance imaging gold standard. J Am Coll Cardiol 2007;50(11): 1021–8. [15] Porter A, Sclarovsky S, Ben-Gal T, Herz I, Solodky A, Sagie A. Value of T-wave direction with lead III ST segment depression in acute anterior wall myocardial infarction: electrocardiographic prediction of a “wrapped” left anterior descending artery. Clin Cardiol 1998;21(8):562–6. [16] Atar S, Barbagelata A, Birnbaum Y. Electrocardiographic diagnosis of ST-elevation myocardial infarction. Cardiol Clin 2006;24:343–65. [17] Nair R, Glancy DL. ECG discrimination between right and left circumflex coronary arterial occlusion in patients with acute inferior myocardial infarction: value of old criteria and use of lead aVR. Chest 2002;122:134–9. [18] Wong CK, Freedman SB. Electrocardiographic identification of the infarctrelated artery in acute inferior myocardial infarction. Int J Cardiol 1996;54: 5–11. [19] Sun TW, Wang LX, Zhang YZ. The value of ECG lead aVR in the differential diagnosis of acute inferior wall myocardial infarction. Intern Med 2007;46: 795–9. [20] Kanei Y, Sharma J, Diwan R, Sklash R, Vales LL, Fox JT, et al. ST-segment depression in aVR as a predictor of culprit artery and infarct size in acute inferior wall ST segment elevation myocardial infarction. J Electrocardiol 2010;43:132–5. [21] Menown IB, Adgey AA. Improving the ECG classification of inferior and lateral myocardial infarction by inversion of lead aVR. Heart 2000;83: 657–60. [22] Kosuge M, Kimura K, Ishikawa T, Ebina T, Hibi K, Toda N, et al. ST-segment depression in lead aVR: a useful predictor of impaired myocardial reperfusion in patients with inferior acute myocardial infarction. Chest 2005;128: 780–6.
http://dx.doi.org/10.1016/j.ajem.2015.04.075 References [1] Fuchs RM, Achuff SC, Grunwald L, Yin FC, Griffith LS. Electrocardiographic Localization of coronary artery narrowings: studies during myocardial ischemia and infarction in patients with one vessel disease. Circulation 1982;66(6): 1168–76. [2] Myocardial infarction redefined: a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction. Eur Heart J 2000;21:1502–13. [3] Anderson ST, Pahlm O, Selvester RH, Bailey JJ, Berson AS, Barold SS, et al. A panoramic display of the orderly sequenced twelve lead electrocardiogram. J Electrocardiol 2004;27:347–52. [4] Brady WJ, Perron AD, Chan T. Electrocardiographic ST-segment elevation: correct identification of acute myocardial infarction (AMI) and non-AMI syndromes by emergency physicians. Acad Emerg Med 2001;8:349–60. [5] Perron A, Lim T, Pahlm-Webb U, Wagner GS, Pahlm O. Maximal increase in sensitivity with minimal loss of specificity for diagnosis of acute coronary occlusion achieved by sequentially adding leads from the 24-lead electrocardiogram to the orderly sequenced 12-lead electrocardiogram. J Electrocardiol 2007;40(6): 463–9. [6] Pahlm U, Pahlm O, Wagner GS. The 24-lead ECG display for enhanced recognition of STEMI equivalent patterns in the 12-lead ECG. J Electrocardiol 2014;47(4): 425–9. [7] Sgarbossa EB, Barold SS, Pinski SL, Wagner GS, Pahlm O. Twelve-lead electrocardiogram: the advantages of an orderly frontal lead display including lead -aVR. J Electrocardiol 2004;37(3):141–7. [8] Shah A, Wagner GS, Green CL, Crater SW, Sawchak ST, Wildermann NM, et al. Electrocardiographic differentiation of the ST segment depression of acute epicardial injury due to left circumflex artery occlusion from that of subendocardial injury due to non-occlusive ischemia. Am J Cardiol 1997;80:512–3. [9] Hasdai D, Yeshurun M, Birnbaum Y, Sclarovsky S. Inferior wall acute myocardial infarction with one lead ST-segment elevation: electrocardiographic distinction between a benign and a malignant clinical course. Coron Artery Dis 1995;6: 875–81. [10] De Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982; 103(4):730–6. [11] Iwasaki K, Kusachi S, Kita T, Taniguchi G. Prediction of isolated first diagonal branch occlusion by 12-lead electrocardiography: ST segment shift in leads I and aVL. J Am Coll Cardiol 1994;23(7):1557–61. [12] Birnbaum Y, Sclarovsky S, Mager A, Strasberg B, Rechavia E. ST segment depression in a VL: a sensitive marker for acute inferior myocardial infarction. Eur Heart J 1993; 14:4–7.
The outcomes of elderly ED patients intubated because of community acquired pneumonia: Why not give noninvasive ventilation a chance? To the Editor, We have read the study regarding the impact of age on outcomes of elderly patients admitted to emergency department (ED) because of severe community acquired pneumonia (CAP) and treated with invasive mechanical ventilation (IMV) by Hifumi et al [1] with great interest. The authors investigated patients older than 65 years who were divided in 3 groups (65-74, 75-84, and 85 years or older). No significant differences were observed among the 3 groups on mechanical ventilation (MV), hospital mortality, ventilator-free days, or intensive care unit (ICU) days. The authors conclude that age, in itself, may not be a factor limiting the initiation of MV in the ED in advanced age with CAP. This conclusion, among other contentions, in Hifumi et al demands some perspective. We provide some observations based on our experience with the treatment of CAP in elderly patients. 1. As previously reported, the proportion of elderly persons among hospitalized patients, including ICU admissions, is rapidly increasing in developed countries: very old patients represent 10% to 15% of ICU admissions [2]. In patients with chronic obstructive pulmonary disease with hypercapnia, noninvasive ventilation (NIV) achieved high rate of success in very old patients, and MV was of questionable value [3]. Did the authors consider in less severely ill patients (as measured by objective parameters) the use of NIV before IMV, which can decrease the need of intubation and ICU mortality [4]? 2. Numerous previous studies have suggested that age alone is not a reliable predictor of mortality in the critically ill patients. Other predictors including disease severity using objective criteria, body mass index, functional impairment, or the presence of an underlying fatal disease account for poor outcomes in elderly cohorts [5]. It would be of great interest to know if the authors considered illness severity