Top

Published in:

Open Access 01-11-2021 | Pleural Effusion | Original Paper

Prognostic value of the chest X-ray in patients hospitalised for heart failure

Authors: Daniel Pan, Pierpaolo Pellicori, Karen Dobbs, Jeanne Bulemfu, Ioanna Sokoreli, Alessia Urbinati, Oliver Brown, Shirley Sze, Alan S. Rigby, Syed Kazmi, Jarno M. Riistama, John G. F. Cleland, Andrew L. Clark

Published in: Clinical Research in Cardiology | Issue 11/2021

Abstract

Background

Patients admitted to hospital with heart failure will have had a chest X-ray (CXR), but little is known about their prognostic significance. We aimed to report the prevalence and prognostic value of the initial chest radiograph findings in patients admitted to hospital with heart failure (acute heart failure, AHF).

Methods

The erect CXRs of all patients admitted with AHF between October 2012 and November 2016 were reviewed for pulmonary venous congestion, Kerley B lines, pleural effusions and alveolar oedema. Film projection (whether anterior–posterior [AP] or posterior–anterior [PA]) and cardiothoracic ratio (CTR) were also recorded. Trial registration: ISRCTN96643197

Results

Of 1145 patients enrolled, 975 [median (interquartile range) age 77 (68–83) years, 61% with moderate, or worse, left ventricular systolic dysfunction, and median NT-proBNP 5047 (2337–10,945) ng/l] had an adequate initial radiograph, of which 691 (71%) were AP. The median CTR was 0.57 (IQR 0.53–0.61) in PA films and 0.60 (0.55–0.64) in AP films. Pulmonary venous congestion was present in 756 (78%) of films, Kerley B lines in 688 (71%), pleural effusions in 649 (67%) and alveolar oedema in 622 (64%).

A CXR score was constructed using the above features. Increasing score was associated with increasing age, urea, NT-proBNP, and decreasing systolic blood pressure, haemoglobin and albumin; and with all-cause mortality on multivariable analysis (hazard ratio 1.10, 95% confidence intervals 1.07–1.13, p < 0.001).

Conclusions

Radiographic evidence of congestion on a CXR is very common in patients with AHF and is associated with other clinical measures of worse prognosis.

Graphic abstract

Donkor A, McDonagh T, Hardman S (2017) National heart failure audit April 2015 to March 2016. National Institute for Cardiovascular Outcomes Research (NICOR), London

Mebazaa A, Yilmaz MB, Levy P et al (2015) Recommendations on pre-hospital & early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine. Eur J Heart Fail 17:544–558. https://doi.org/10.1002/ejhf.289CrossRefPubMed

Ponikowski P, Voors AA, Anker SD et al (2016) 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 37:2129–2200m. https://doi.org/10.1093/eurheartj/ehw128CrossRefPubMed

Danzer CS (1919) The cardio-thoracic ratio: an index of cardiac enlargement. Am J Med Sci 157:513–552CrossRef

Gluecker T, Capasso P, Schnyder P et al (1999) Clinical and radiologic features of pulmonary edema. Radiographics 19:1507–1531. https://doi.org/10.1148/rg.242035075CrossRefPubMed

Gheorghiade M, Follath F, Ponikowski P et al (2010) Assessing and grading congestion in acute heart failure: a scientific statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine. Eur J Heart Fail 12:423–433. https://doi.org/10.1093/eurjhf/hfq045CrossRefPubMed

Clark AL, Coats AJS (2000) Unreliability of cardiothoracic ratio as a marker of left ventricular impairment: Comparison with radionuclide ventriculography and echocardiography. Postgrad Med J 76:289–291. https://doi.org/10.1136/pmj.76.895.289CrossRefPubMedPubMedCentral

Allen CJ, Guha K, Sharma R (2015) How to improve time to diagnosis in acute heart failure—clinical signs and chest X-ray. Card Fail Rev 1(2):69–74. https://doi.org/10.15420/cfr.2015.1.2.69

Petrie MC, McMurray JJV (2003) It cannot be cardiac failure because the heart is not enlarged on the chest x-ray. Eur J Heart Fail 5:117–119. https://doi.org/10.1016/S1388-9842(02)00239-8CrossRefPubMed

10.

Roguin A, Behar D, Ben Ami H et al (2000) Long-term prognosis of acute pulmonary oedema—an ominous outcome. Eur J Hear Fail J Work Gr Hear Fail Eur Soc Cardiol 2:137–144. https://doi.org/10.1016/S1388-9842(00)00069-6CrossRef

11.

Battler A, Karliner JS, Higgins C et al (1980) The initial chest X-ray in acute myocardial infarction prediction of early and late mortality and survival. Circ 61(5):1004-1009. https://doi.org/10.1161/01.cir.61.5.1004

12.

Brezins M, Benari B, Pap V, Cohen A, Bursztein S, Markiewicz W (1993) Left ventricular function in patients with acute myocardial infarction, acute pulmonary edema, and mechanical ventilation: relationship to prognosis. Crit Care Med 21:380–385CrossRefPubMed

13.

Lin M, Yang YF, Chiang HT et al (1995) Reappraisal of continuous positive airway pressure therapy in acute cardiogenic pulmonary edema: Short-term results and long-term follow-up. Chest 107:1379–1386. https://doi.org/10.1378/chest.107.5.1379CrossRefPubMed

14.

Burch G, DePasquale N (1969) Congestive heart failure—acute pulmonary edema. JAMA 208:1895–1897CrossRefPubMed

15.

Packer M (2019) Why are physicians so confused about acute heart failure? N Engl J Med 381:774–776. https://doi.org/10.1056/nejme1909053CrossRef

16.

Clark AL, Cleland JGF (2013) Causes and treatment of oedema in patients with heart failure. Nat Rev Cardiol 10:156–170. https://doi.org/10.1038/nrcardio.2012.191CrossRefPubMed

17.

Nikitin NP, Witte KKA, Thackray SDR et al (2003) Effect of age and sex on left atrial morphology and function. Eur J Echocardiogr 4:36–42. https://doi.org/10.1053/euje.2002.0611CrossRefPubMed

18.

Shelton RJ, Clark AL, Goode K et al (2006) The diagnostic utility of N-terminal pro-B-type natriuretic peptide for the detection of major structural heart disease in patients with atrial fibrillation. Eur Heart J 27:2353–2361. https://doi.org/10.1093/eurheartj/ehl233CrossRefPubMed

19.

Kabala JE, Wilde P (1987) The measurement of heart size in the antero-posterior chest radiograph. Br J Radiol 60:981–986. https://doi.org/10.1259/0007-1285-60-718-981CrossRefPubMed

20.

Austin PC, Lee DS, D’Agostino RB, Fine JP (2016) Developing points-based risk-scoring systems in the presence of competing risks. Stat Med 35:4056–4072. https://doi.org/10.1002/sim.6994CrossRefPubMedPubMedCentral

21.

Bartlett JW, Frost C (2008) Reliability, repeatability and reproducibility: analysis of measurement errors in continuous variables. Ultrasound Obstet Gynecol 31:466–475. https://doi.org/10.1002/uog.5256CrossRefPubMed

22.

Melenovsky V, Andersen MJ, Andress K et al (2015) Lung congestion in chronic heart failure: haemodynamic, clinical, and prognostic implications. Eur J Heart Fail 17:1161–1171. https://doi.org/10.1002/ejhf.417CrossRefPubMed

23.

Seah JCY, Tang JSN, Kitchen A et al (2019) Chest radiographs in congestive heart failure: visualizing neural network learning. Radiology 290:514–522. https://doi.org/10.1148/radiol.2018180887CrossRefPubMed

24.

European Commission (2021) European Guidelines on Quality Criteria for Diagnostic Images. https://www.sprmn.pt/pdf/EuropeanGuidelineseur16260.pdf. Accessed 17 Mar 2021

25.

Arora S, Patel P, Lahewala S et al (2017) Etiologies, Trends, and Predictors of 30-Day Readmission in Patients With Heart Failure. Am J Cardiol 119:760–769. https://doi.org/10.1016/j.amjcard.2016.11.022CrossRefPubMed

26.

Aggarwal S, Gupta V (2014) Demographic parameters related to 30-day readmission of patients with congestive heart failure: Analysis of 2,536,439 hospitalizations. Int J Cardiol 176:1343–1344. https://doi.org/10.1016/j.ijcard.2014.07.140CrossRefPubMed

27.

Saito M, Negishi K, Marwick TH (2016) Meta-analysis of risks for short-term readmission in patients with heart failure. Am J Cardiol 117:626–632. https://doi.org/10.1016/j.amjcard.2015.11.048CrossRefPubMed

28.

Lourenço P, Ribeiro A, Cunha FM et al (2016) Is there a heart rate paradox in acute heart failure? Int J Cardiol 203:409–414. https://doi.org/10.1016/j.ijcard.2015.10.129CrossRefPubMed

29.

Kobayashi M, Bercker M, Huttin O et al (2019) Chest X-ray quantification of admission lung congestion as a prognostic factor in patients admitted for worsening heart failure from the ICALOR cohort study. Int J Cardiol. https://doi.org/10.1016/j.ijcard.2019.06.062CrossRefPubMedPubMedCentral

30.

Mullens W, Damman K, Harjola VP et al (2019) The use of diuretics in heart failure with congestion—a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 21:137–155. https://doi.org/10.1002/ejhf.1369CrossRefPubMed

31.

Kobayashi M, Watanabe M, Coiro S et al (2019) Mid-term prognostic impact of residual pulmonary congestion assessed by radiographic scoring in patients admitted for worsening heart failure. Int J Cardiol 289:91–98. https://doi.org/10.1016/j.ijcard.2019.01.091CrossRefPubMed

Title: Prognostic value of the chest X-ray in patients hospitalised for heart failure
Authors: Daniel Pan
Pierpaolo Pellicori
Karen Dobbs
Jeanne Bulemfu
Ioanna Sokoreli
Alessia Urbinati
Oliver Brown
Shirley Sze
Alan S. Rigby
Syed Kazmi
Jarno M. Riistama
John G. F. Cleland
Andrew L. Clark
Publication date: 01-11-2021
Publisher: Springer Berlin Heidelberg
Keywords: Pleural Effusion
Heart Failure
Acute Heart Failure
Published in: Clinical Research in Cardiology / Issue 11/2021
Print ISSN: 1861-0684
Electronic ISSN: 1861-0692
DOI: https://doi.org/10.1007/s00392-021-01836-9

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.

Watch now

At a glance: The STEP trials

Springer Medicine

Prognostic value of the chest X-ray in patients hospitalised for heart failure

Abstract

Background

Methods

Results

Conclusions

Graphic abstract

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Graphic abstract

Please log in to get access to this content

Other articles of this Issue 11/2021

Cardiac amyloidosis CT sign

Patients with acute myocarditis and preserved systolic left ventricular function: comparison of global and regional longitudinal strain imaging by echocardiography with quantification of late gadolinium enhancement by CMR

Left ventricular noncompaction and Fabry disease: two diagnoses in one heart?

Echocardiographic diagnosis of atrial cardiomyopathy allows outcome prediction following pulmonary vein isolation

SARS-CoV-2, myocardial injury and inflammation: insights from a large clinical and autopsy study

Short- and long-term outcome of patients with spontaneous echo contrast or thrombus in the left atrial appendage in the era of the direct acting anticoagulants

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page