Recognizing Cardiomegaly

Dr. Josef Siregar

Cardio-thoracic Ratio

One of the easiest observations to make is the cardio-thoracic ratio which is the widest diameter of the heart compared to the widest internal diameter of the rib cage

<50%

In most normal people the cardio-thoracic ratio is less than 50%

Sometimes, the cardiothoracic ratio is >50% but the heart is still normal
These are the causes:

CTR is more than 50% But Heart is Normal

Extracardiac causes of cardiac enlargement

Portable AP films Obesity Pregnant Ascites Straight back syndrome Pectus excavatum

Effect of AP versus PA film on heart size

AP

PA

This slide demonstrates the effect of magnification on heart size. The heart sits anteriorly in the chest. On a PA chest film (the standard frontal chest in which the x-ray beam enters posteriorly and exits anteriorly), the heart shows little magnification.

Effect of AP versus PA film on heart size

AP

PA

On an AP chest film (the usual portable chest radiograph in which the xray beam enters anteriorly and exits posteriorly), there is more magnification. Look at the size of the heart in the two films on the same patient side by side.

Effect of Inspiratory effort on heart size

Inspiration

Expiration

In expiration the heart appears larger than it does on full inspiration. A pregnant patient, one with ascites, or an obese patient might not be able to take a full inspiration which might make the heart look bigger than it actually is. Eight to nine posterior ribs showing is a good inspiration.

Effect of chest wall deformity on heart size

>50%

The lower portion of this patients sternum bows inward toward the heart. The heart is compressed between the sternal abnormality (which is called a pectus excavatum deformity) and the spine. On the frontal radiograph, the heart may appear enlarged.

Cardiomegaly and the AP Film

How can you tell if the heart is enlarged on an AP (usually portable) film

If the heart touches the lateral chest wall, its enlarged

Enlarged or not?

Enlarged or not?

Yes

Enlarged or not?

Enlarged or not?

Yes

Enlarged or not?

Enlarged or not?

No

Enlarged or not?

Enlarged or not?
This is a pectus excavatum deformity of the sternum which is compressing the heart and making it appear larger than it really is. The clue to the deformity on the frontal film is the extreme downward orientation of the anterior ribs.

No

Enlarged or not?

Enlarged or not?

Yes