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Chest XRay in Congestive Heart Failure

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Chest XRay in Congestive Heart Failure, CHF Chest XRay, Chest XRay in Left Ventricular Failure

  • See Also
  1. Congestive Heart Failure
  2. Echocardiogram in Congestive Heart Failure
  3. Chest XRay Interpretation
  • Pathophysiology
  • Progression of chronic CHF
  1. Stage 1: Pulmonary venous Hypertension with prominent upper lobe vessels (cephalization)
  2. Stage 2: Interstitial Infiltrates (Kerley B Lines, peribronchial cuffing)
  3. Stage 3: Alveolar Infiltrates (and Pleural Effusions)
    1. Interstitial fluid leak overwhelms lymphatic drainage capacity, overflowing into alveoli and pleural space
    2. Acute Pulmonary Edema typically presents with Stage III findings (without stage I or II)
  • Imaging
  • Stage 1 CHF XRay findings - Vascular phase - pulmonary venous Hypertension
  1. Cardiomegaly
    1. May be absent in acute Cardiomyopathy (e.g. Takotsubo Cardiomyopathy)
  2. Pulmonary vasculature redistribution (Cephalization)
    1. Upper pulmonary vasculature becomes more prominent (upright Chest XRay)
    2. Normal, healthy patients have prominent lower lung field vasculature in contrast (upright Chest XRay)
    3. Redistribution will not be seen on supine xray
    4. Test Specificity: 80-90% for increased ventricular filling pressure
  3. Increased artery to Bronchus ratio
    1. Perihilar and upper lobe arteries (white round densities)
      1. Normally smaller in cross-section than Bronchi (dark round densities)
    2. Pulmonary vascular redistribution
      1. Results in an increased pulmonary artery diameter, larger than the bronch (ratio >1)
  4. Vascular pedicle broadens
    1. Mediastinal width increases at the level of the aortic arch or knob
  5. Pulmonary capillary wedge pressure (PCWP): 13-18 mmHg
  • Imaging
  • Stage 2 CHF XRay findings - Interstitial phase
  1. Kerley B Lines (Interstitial Infiltrates)
    1. Short (1-2 cm) peripheral, lower lobe white lines, perpendicular and adjacent to pleura
    2. Represent edematous interlobular septa (specific for Cardiogenic Pulmonary Edema)
  2. Peribronchial cuffing
    1. Bronchial wall thickening from Interstitial Edema (white rim around dark Bronchioles)
    2. May be normal when seen centrally, but is pathologic when found peripherally
    3. Non-specific finding indicating increased interstitial fluid
      1. Similar findings are seen in Viral Pneumonia (esp. children)
  3. Vessels become less distinct
    1. Hazy contours result from surrounding edema (perihilar haze)
  4. Interlobar fissure thickens
    1. Brighter white line between the lung lobes (esp. right horizontal fissure, at base of right upper lobe)
    2. Represents interface between edematous lungs (not necessarily fluid in the fissure itself)
  5. Pulmonary capillary wedge pressure (PCWP): 18-25 mmHg
  • Imaging
  • Stage 3 CHF XRay findings - Alveolar phase
  1. Alveolar Infiltrates (Cottonwool appearance)
    1. Congestion is most dramatic centrally and in basal regions (bat-wing or butterfly appearance)
    2. Acute Pulmonary Edema (e.g. acute Left Ventricular Failure) may present with diffuse white-out appearance
  2. Air Bronchograms
    1. Dark Bronchioles become prominent in a background of white, fluid filled alveoli
  3. Pleural Effusion
  4. Pulmonary capillary wedge pressure (PCWP): >25 mmHg
  • Imaging
  • Other findings
  1. Underlying lung disease
  2. Chamber enlargement
  3. Valve calcifications
  • Differential Diagnosis
  1. See Chest XRay Interpretation
  2. Acute Respiratory Distress Syndrome (ARDS)
    1. History of major trigger (e.g. Trauma or surgery)
    2. No cardiomegaly
    3. No Pleural Effusions
  1. Most useful initial test to assess for Congestive Heart Failure (as well as other causes of Dyspnea)
  2. Test Sensitivity: 71%
  3. Test Specificity: 92%
  • Resources
  1. Congestive Heart Failure (Loyola Stritch School of Medicine)
    1. https://www.stritch.luc.edu/lumen/meded/radio/curriculum/medicine/chf1.htm
  2. Cremers, Bradshaw and Herfkens, Chest X-Ray - Heart Failure (Radiology Assistant)
    1. https://radiologyassistant.nl/chest/chest-x-ray/heart-failure
  3. Congestive Cardiac Failure (Radiopaedia)
    1. https://radiopaedia.org/articles/congestive-cardiac-failure?lang=us
  • References
  1. Tubbs and Janicki (2025) Adult CXR Non-Traumatic, Mastering Emergency Imaging, CCME, accessed 2/14/2026