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European Journal of Heart Failure 2003 5(2):117-119; doi:10.1016/S1388-9842(02)00239-8
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© 2002 European Society of Cardiology

It cannot be cardiac failure because the heart is not enlarged on the chest X-ray

Mark C. Petrie*

Department of Cardiology Western Infirmary of Glasgow Glasgow, Scotland, UK

* Corresponding author. CRI in Heart Failure, Wolfson Building, University of Glasgow, Glasgow G12 8QQ, UK. Tel./fax: +44-141-330-6588 E-mail address: j.mcmurray{at}bio.gla.ac.uk

Received February 11, 2002; Revised September 2, 2002; Accepted September 13, 2002

A common maxim, often repeated on ward rounds and in outpatient clinics, is that a patient cannot have cardiac failure if the heart size is normal on the chest X-ray [1]. As the list of evidence-based, life-saving, treatments for patients with heart failure due to left ventricular systolic dysfunction grows ever longer it is time to lay this fallacy to rest.

There is now a wealth of data to show that patients of the sort that were randomised into the landmark clinical trials, with a significant reduction in left ventricular systolic function, can have a normal heart size on the chest X-ray [1–19].

This is readily apparent from a quick examination of some of the published trials (Table 1) [2–19]. As can be seen up to two thirds of patients have some degree of cardiac enlargement, measured as a cardiothoracic ratio (CTR) of >=0.5. Only about a third have unequivocal cardiac enlargement (a CTR of >0.55). Yet the average left ventricular ejection fraction (LVEF) was severely depressed in all trials.


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  		Table 1 Cardiothoracic ratio in large heart failure trials

 
In another study, radionuclide LVEF, echocardiographic left ventricular dimensions and function and CTR were measured in 91 patients with CHF [20]. There was only a weak correlation between CTR and the other measures [20].

Closer inspection of particular trials, giving detailed information, illuminates the point further. For example, in the DIG trial, a LVEF of <=0.35 (which would have qualified a patient for any of the recent beta-blocker trials) [21–23] was present in 59% of patients with a CTR of <0.50 and 64% of patients with a CTR of <=0.55 [8–10]. Atrial fibrillation and right ventricular enlargement are confounding influences. Patients with atrial fibrillation in the second vasodilator Heart Failure Trial (VHeFT II) had a higher CTR than those in sinus rhythm (0.56 versus 0.52, P<0.00001), despite also having a higher LVEF (32% versus 29%, P=0.01) and smaller left ventricular internal dimension (3.3 cm/m2 versus 3.5 cm/m2, P=0.01) [4]. This observation can be explained by the contribution of the atria to the cardiac silhouette; the left atrial dimension in VHeFT II was 51.8 mm in patients in atrial fibrillation compared to 45.8 mm in sinus rhythm (P<0.00001) [4]. Right ventricular enlargement is similarly confounding. In the DIG trial the CTR was 0.55 in patients with right ventricular dysfunction compared to 0.53 in those without, despite patients with right ventricular dysfunction having a similar LVEF (31.9% versus 31.1%) [10].

It should also be remembered that, even in the absence of atrial fibrillation and right ventricular dysfunction, an increased CTR need not reflect a reduced LVEF. Left ventricular hypertrophy, for example, can cause radiographic cardiomegaly. This may explain the findings of the Coronary Artery Surgery Study investigators [24]. In their registry population, which had a low prevalence of impaired left ventricular systolic function (23%), 66% of 1397 patients with a CTR >0.50 had a normal LVEF [24].

The message is clear. A normal heart size does not exclude significant, or even severe, left ventricular systolic dysfunction in a patient with suspected heart failure. This is in marked contra-distinction to the 12-lead electrocardiogram (ECG) which, if grossly normal, virtually rules out left ventricular systolic dysfunction [24–27]. Indeed, heart size on the chest X-ray adds little additional information to that obtained from the 12-lead ECG [24]. Of course, other findings on the chest X-ray, such as pulmonary congestion or oedema, may support a diagnosis of cardiac dysfunction, though these are less common findings than cardiomegaly. Conversely, there may be abnormalities suggesting alternative diagnoses e.g. a lung tumour, pulmonary fibrosis etc.

Though heart size on the chest X-ray is of limited diagnostic value, it is of considerable prognostic value in the patient with CHF and a low LVEF. A higher CTR is predictive of the risk of progression to New York Heart Association Class IV CHF (23% of those with a CTR of >0.50 versus 5% of patients with a CTR of <=0.50, odds ratio 5.4, P=0.017)[28] and hospitalisation [3].

In multivariate analyses, a bigger CTR is also a powerful predictor of increased mortality [2]. In VHeFT II, the risk ratio for death (compared to a ratio of 1.0 for a CTR of <=0.49) was 1.67 for a CTR of >0.49–<=0.53 (P<0.01), 2.30 for a CTR >0.53–<=0.57 (P<0.001) and 3.53 for a CTR of >0.57 (P<0.001). Indeed, CTR added important, additional, prognostic information to any given LVEF and in patients with ventricular arrhythmias [2].

Interestingly, a high CTR may also be a predictor of response to therapy. This certainly seems to be the case for digoxin [9]. The proportion of patients in the DIG trial with a CTR >0.55 experiencing death from, or hospitalisation for, worsening CHF in the placebo group was 48.5% compared to 37.5% in the digoxin group (risk ratio 0.69, 95% CI 0.61–0.78) [9]. For patients with a CTR <=0.55 these proportions were 32.4% and 27.0% (risk ratio 0.79, 0.71–0.88) [9]. The P value for the interaction between treatment and CTR was 0.02, indicating that digoxin was significantly more effective in patients with a higher CTR [9].

In summary, the cardiomegaly on the chest X-ray is not a pre-requisite for the diagnosis of heart failure due to left ventricular systolic dysfunction and around a third of patients like this will have a normal CTR. Neither does an increased CTR indicate the presence of left ventricular systolic dysfunction and further investigation, using echocardiography, is indicated in patients with suspected heart failure or radiological cardiomegaly. An increased CTR is of great prognostic importance in patients with proven left ventricular systolic dysfunction and also identifies patients more likely to benefit from treatment with digoxin.


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