Congestive heart failure chest x ray

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ACC/AHA Guideline Recommendations Initial and Serial Evaluation of the HF Patient Hospitalized Patient Patients With a Prior MI Sudden Cardiac Death Prevention Surgical/Percutaneous/Transcather Interventional Treatments of HF Patients at high risk for developing heart failure (Stage A) Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B) Patients with current or prior symptoms of heart failure (Stage C) Patients with refractory end-stage heart failure (Stage D) Coordinating Care for Patients With Chronic HF Quality Metrics/Performance Measures
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Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

The chest x-ray in the patient with heart failure shows cardiomegaly (cardiac enlargement and pulmonary congestion (Kerley B lines, and in some cases pleural effusion)

Chest X-ray

• Since the left ventricle often dilates in the anteroposterior direction, the cardiac silhouette may appear deceptively normal.

• Chest x-ray findings include:

1. Kerley B lines or thickening of the interlobular septa
2. Peribronchial cuffing
3. Thickening of the fissures
4. Cephalization
5. Increased vascular markings
6. Interstitial edema
7. Pleural effusions

Kerley B Lines

Kerley B lines are short parallel lines at the lung periphery. These lines represent distended interlobular septa, which are usually less than 1 cm in length and parallel to one another at right angles to the pleura. They are located peripherally in contact with the pleura, but are generally absent along fissural surfaces. They may be seen in any zone but are most frequently observed at the lung bases at the costophrenic angles on the PA radiograph, and in the substernal region on lateral radiographs.

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  Plain film: Mitral stenosis, Kerley B lines

• 

  Plain film: Mitral stenosis, Kerley B lines

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  Plain film: Mitral stenosis, Kerley B lines

Peribronchial Cuffing

The red arrows point to thickened bronchial walls that have a doughnut-like appearance.

Peribronchial cuffing is an abnormality on a chest x-ray whereby the usually thin bronchial walls are thickened and take on a doughnut-like appearance.

Cephalization

Cephalization refers to the redistribution of blood into the upper lobe vessels. It has been hypothesized that once the hydrostatic pressure exceeds 10 mm Hg, then fluid begins to leak into the interstitium of the lung. This excess fluid initially compresses the lower lobe vessels, perhaps as a result of gravity. After this, the upper lobe vessels are recruited to distribute a greater volume of blood. In order to carry a greater volume of blood, the upper lobe vessels increase in size.

Differentiating Cardiogenic Versus Noncardiogenic Pulmonary Edema

Cardiogenic Pulmonary Edema

Cardiogenic pulmonary edema can be distinguished from noncardiogenic pulmonary edema by the presence of redistribution of blood flow to the upper lobes (increased blood flow to the higher parts of the lung) and interstitial edema.

Noncardiogenic Pulmonary Edema

In contrast, patchy alveolar infiltrates with air bronchograms are more indicative of noncardiogenic edema.

Correlation of Chest X-Ray Findings with Pulmonary Capillary Wedge Pressure

• Normal:5-10 mm Hg
• Cephalization: 10-15 mm Hg
• Kerley B Lines: 15-20 mm Hg
• Pulmonary Interstitial Edema: 20-25 mm Hg
• Pulmonary Alveolar Edema: > 25 mm Hg

ACC/AHA Guidelines- Chest X Ray Recommendation

Class I

1. Twelve-lead electrocardiogram and chest radiograph (PA and lateral) should be performed initially in all patients presenting with heart failure. (Level of Evidence: C)

Vote on and Suggest Revisions to the Current Guidelines

• The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

• 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation

References

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