RD7.3 | Imaging Findings in Cardiac Failure — Summary & Reflection

KEY TAKEAWAYS

Imaging Findings in Cardiac Failure — Key Points

• Imaging answers three questions in heart failure: is the heart enlarged, is there pulmonary congestion, and what is the ejection fraction? Natriuretic peptides (BNP/NT-proBNP) help decide who needs urgent imaging.
• The chest radiograph (CXR) is the first-line bedside study — fast, portable, shows cardiomegaly and congestion immediately and lets decongestion begin. It cannot measure cardiac function.
• Transthoracic echocardiography is the key functional modality — it measures the left-ventricular ejection fraction (LVEF) and classifies failure as HFrEF (<40%), HFmrEF (41–49%) or HFpEF (≥50%), and identifies the structural cause.
• CXR signs follow rising pulmonary venous pressure in order: cardiomegaly (CTR >0.5), upper-lobe blood diversion (cephalisation), Kerley B lines, peribronchial cuffing, alveolar (bat-wing) oedema, and pleural effusions.
• Advanced modalities are for problem-solving: cardiac MRI for ventricular volumes/EF and tissue characterisation (aetiology, viability); lung ultrasound B-lines for rapid congestion monitoring; CT/coronary CT for coronary and structural assessment (avoid iodinated contrast if eGFR <30).
• Management is imaging-driven: congestion on CXR → diuresis/oxygen/vasodilators (± CPAP); EF on echo → guideline-directed therapy (HFrEF gets the four foundational drug classes ± device therapy; HFpEF gets decongestion, BP/comorbidity control, SGLT2 inhibitor).
• Imaging distinguishes cardiogenic from non-cardiogenic oedema: cardiomegaly + upper-lobe diversion + effusions + low EF (cardiogenic) versus normal heart size + peripheral opacities + normal EF (ARDS/non-cardiogenic).

REFLECT

On your next medical or casualty shift, when a breathless patient has a chest radiograph taken, pause to read it as a haemodynamic record rather than a checklist: where on the congestion cascade does this patient sit — early upper-lobe diversion, or full bat-wing oedema? Then follow the patient to the echocardiogram and ask what the ejection fraction was, and notice whether the team chose the long-term therapy on the basis of the EF category or by habit. Ask whether anyone considered whether the 'oedema' was truly cardiogenic. Consciously linking each imaging finding to a management decision — congestion to diuresis, EF to drug choice, heart size to the cardiogenic-versus-non-cardiogenic question — is how the imaging stops being a report to file and becomes a tool for clinical reasoning.