Left Heart Failure – CXR

Table of Contents

Table of Contents

Published February 2021

Daniel Gergen, MD
Samantha King, MD
Expert review – pending

Objective(s)

  1. Identify key features to identify and determine the severity of congestive left heart failure on a chest x-ray.

Teaching Instructions

Plan to spend 5-10 minutes familiarizing yourself with the animations of the PowerPoint and the key findings of this chest X-ray.

Instructions: Present the image either by expanding the window (bottom right) in a browser or downloading the PowerPoint file (downloading is recommended.  Have the image pulled up in presenter mode before learners look at the screen to avoid revealing the diagnosis.  Ask a learner to provide an overall interpretation.  Then advance through the animations to prompt learners with key questions and reveal the findings, diagnosis, and teaching points.  You can go back to prior graphics and questions by using the back arrow or scrolling back on the mouse wheel.

Official CXR Read: Enlarged cardiac silhouette with bilateral perihilar enlargement, haziness, and congestion. In addition, diffuse interstitial and alveolar opacities. Peribronchial cuffing is present. Kerley B lines are also observed at the periphery. Small left pleural effusion.

Diagnosis: Pulmonary edema secondary to cardiogenic shock

Teaching:

    • An enlarged cardiac silhouette is defined as a cardiac silhouette that is greater than half of the internal thoracic diameter. The differential for an enlarged cardiac silhouette on chest radiograph includes, cardiomegaly, pericardial effusion, and portable/AP film.
    • The differential for perihilar enlargement includes lymphadenopathy, malignancy, pulmonary arterial hypertension, and pulmonary venous hypertension. In the setting of STEMI and cardiogenic shock, acute perihilar enlargement is attributed to pulmonary venous hypertension.
    • This radiograph demonstrates a diffuse interstitial pattern. Other terms that could be utilized to describe this pattern are linear or reticular. In this case, the interstitial markings emanate from the hilum bilaterally and reach approximately 2/3 of the way to the pleural surface. Considering the clinical context, this is most consistent with cardiogenic pulmonary edema.

 

Radiographic stages of acute left heart failure (based on pulmonary capillary wedge pressure):

Stage 1 (PCWP 18 mmHg): cephalization of the upper lobe pulmonary vasculature. Best described as increased prominence of the upper lobe vasculature due to redistribution of blood flow.

Stage 2 (PCWP 22 mmHg): increased interstitial prominence, peribronchial cuffing, perihilar enlargement, and Kerley B lines.

Stage 3 (PCWP 25 mmHg): alveolar opacities.

Presentation Board

Take Home Point

Radiographic evidence of cardiogenic pulmonary edema progress along 3 stages that correlate with pulmonary capillary wedge pressure (PCWP):

Stage 1 (PCWP 18 mmHg): cephalization of the upper lobe pulmonary vasculature. Best described as increased prominence of the upper lobe vasculature due to redistribution of blood flow.

Stage 2 (PCWP 22 mmHg): increased interstitial prominence, peribronchial cuffing, perihilar enlargement, and Kerley B lines.

Stage 3 (PCWP 25 mmHg): alveolar opacities.

McHugh TJ, Forrester JS, Adler L, Zion D, Swan HJ. Pulmonary vascular congestion in acute myocardial infarction: hemodynamic and radiologic correlations. Ann Intern Med. 1972;76(1):29-33.
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