The role of the chest X-ray in the evaluation of chronic severe heart failure: things are not always as they appear

The chest x-ray has become a standard clinical test to aid in the evaluation of patients with chronic severe heart failure. To evaluate just how useful this tool is in the routine assessment of pulmonary venous hypertension secondary to heart failure, we compared the radiologist's interpretation of the chest x-ray with hemodynamic data obtained from right heart catheterization in a group of patients undergoing protocol evaluation of an experimental treatment for heart failure. Of 23 patients with pulmonary venous hypertension (pulmonary capillary wedge pressure greater than 20 mmHg) and a complete data base, only 11 had chest x-rays showing evidence of pulmonary venous congestion or interstitial or alveolar edema. The sensitivity of the chest x-ray in selecting patients with a pulmonary capillary wedge pressure over 20 mmHg in this setting was only 48%. In other studies, where the radiologist was aware that his or her reading was being compared to hemodynamic assessments, the sensitivity of the chest film has approached 85%. We feel our analysis more closely parallels routine clinical practice. Clinicians should be aware that the chest x-ray may not be a very sensitive tool for the assessment of pulmonary hemodynamics in patients with severe heart failure.