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Chest radiography, to which not even a passing allusion was made in a recent report on misdiagnosis of heart failure, has now been accorded its rightful status in the recognition of this syndrome. Unlike some of the clinical stigmata of pulmonary disease, which have been accorded an importance, in the undergraduate curriculum, disproportionate to their relationship to evidence-based medicine, the radiogra...
Chest radiography, to which not even a passing allusion was made in a recent report on misdiagnosis of heart failure, has now been accorded its rightful status in the recognition of this syndrome. Unlike some of the clinical stigmata of pulmonary disease, which have been accorded an importance, in the undergraduate curriculum, disproportionate to their relationship to evidence-based medicine, the radiographic stigmata of severe chronic left ventricular failure (LVF), although not instilled to the same extent, nevertheless have the merit of having been evaluated for sensitivity, specificity, and positive predictive value, yielding values of 65%, 80%, and 89% respectively, for pulmonary vascular redistribution, and 27%, 87%, and 83%, respectively, for interstitial oedema in the presence of pulmonary capillary wedge pressure > 18 mmHg.
On a 4-point scale of severity, a comparison between clinical and radiographic parameters for LVF generated a concordance which differed by no more than 1 grade, in 94% of instances. Analysis of radiographic parameters also revealed greater interobserver agreement for recognition of interstitial oedema as opposed to pulmonary vascular redistribution (95% vs 74%).
In consequence, this parameter (together with alveolar oedema) deserves recognition in the entirety of its protean manifestations which include, not just the Kerley B lines and "bat's wing" appearance mentioned by the author, but also lower zone "mottled" as well as confluent opacities (some of which may be asymmetrical), and right upper zone opacities (attributable to underlying mitral regurgitation),[6,7] all of which have the potential to be misattributed to pulmonary sepsis.
Overdiagnosis also needs to be avoided, especially in pulmonary embolism (PE), where instead of a positive correlation between clinical and radiographic severity, the degree of breathlessness far outstrips abnormalities (if any) seen on X-ray.
Radiographic abnormalities common to heart failure and PE include pleural effusions which, in heart failure, are reported (sic) more likely to be either bilateral (73%) or right sided (19%), than left sided (9%), a preferential distribution not documented in PE.
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