Cardiogenic shock chest x ray

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2] Syed Musadiq Ali M.B.B.S.[3] James Nasr[4]

Cardiogenic shock chest x ray

Overview

Chest radiography is an initial imaging test in suspected cardiogenic shock because it can identify pulmonary congestion, cardiac enlargement, pleural effusions, alternative thoracic diagnoses, complications of procedures, and the position of invasive support devices. It should be interpreted with the clinical examination, electrocardiogram, laboratory markers, echocardiography, and invasive hemodynamics when available.[1]

A normal chest radiograph does not exclude cardiogenic shock. Pulmonary edema may be absent in early shock, right ventricular-dominant shock, cold-dry shock, acute myocardial infarction-related shock, or chronic heart failure with compensatory lymphatic drainage. Chest radiography is not a reliable stand-alone estimate of pulmonary capillary wedge pressure.[2][3]

Role of chest radiography

The 2017 AHA Scientific Statement notes that chest radiography provides information on cardiac size and pulmonary congestion, may suggest alternative causes such as aortic dissection, pericardial effusion, pneumothorax, esophageal perforation, or pulmonary embolism, and can confirm the position of the endotracheal tube and support devices including temporary pacing wires and mechanical circulatory support.[1] The 2021 AHA/ACC chest pain guideline states that chest radiography is useful in acute chest pain to evaluate for other cardiac, pulmonary, and thoracic causes, but it should not delay urgent revascularization when indicated.[4]

The ACR Appropriateness Criteria for ICU patients rates portable chest radiography as usually appropriate on ICU admission, in clinically worsening patients, and after support device placement.[5]

Function Clinical utility
Assess pulmonary congestion Identifies pulmonary venous congestion, interstitial edema, alveolar edema, and pleural effusions suggesting elevated left-sided filling pressures.[2]
Assess cardiac size Cardiomegaly may suggest chronic heart failure, dilated cardiomyopathy, or pericardial effusion; normal cardiac silhouette may occur in acute heart failure or acute myocardial infarction-related shock.[2]
Identify alternative diagnoses May suggest aortic dissection, pneumothorax, pneumonia, pleural effusion, pulmonary embolism, pericardial effusion, or esophageal perforation.[1][4]
Confirm line and device positioning Confirms or screens the position of endotracheal tube, central venous catheter, pulmonary artery catheter, temporary pacing wires, intra-aortic balloon pump, selected percutaneous ventricular assist devices, ECMO cannulae, and chest tubes.[1]
Monitor clinical course Serial radiographs may assess pulmonary edema, pleural effusions, device migration, pneumothorax, hemothorax, and complications during mechanical circulatory support.[5]

Radiographic findings of pulmonary congestion

Pulmonary congestion and edema on chest radiography reflect increased extravascular lung water and elevated left-sided filling pressures, but the relationship between radiographic findings and measured pulmonary capillary wedge pressure is imprecise. Radiographic changes may lag behind hemodynamic changes.[3]

Finding Description Clinical interpretation
Cephalization Upper lobe pulmonary veins become equal to or larger than lower lobe veins Early sign of pulmonary venous hypertension; difficult to assess on supine portable films.
Peribronchial cuffing Thickened bronchial walls seen end-on Sign of interstitial edema; ≥95% specificity but limited sensitivity for heart failure.[6]
Kerley B lines Short horizontal lines perpendicular to the pleural surface at the lung bases Represent thickened interlobular septa from interstitial edema; ≥95% specificity but limited sensitivity for heart failure.[3][6]
Perihilar haziness Indistinct hilar vascular margins Suggests perivascular edema and increased interstitial fluid.
Alveolar edema Bilateral airspace opacities, often perihilar or central Indicates alveolar flooding; supports cardiogenic pulmonary edema when integrated with cardiac findings and clinical context.
Bilateral pleural effusions Bilateral costophrenic angle blunting or layering pleural fluid Common in heart failure and congestion; unilateral effusion should broaden the differential.
Enlarged cardiac silhouette Cardiothoracic ratio >0.5 on upright PA film Suggests chronic heart failure, cardiomyopathy, or pericardial effusion; may be absent in acute heart failure or acute myocardial infarction.

Diagnostic performance and limitations

Chest radiography has clinically useful specificity for some signs of congestion, but limited sensitivity. The accuracy of identifying congestive heart failure on chest radiograph varies by provider experience, with reported accuracy of approximately 78% for first-year emergency medicine residents, 85% for emergency medicine attendings, and 95% for radiologists.[7]

A systematic review and meta-analysis in adults with symptoms suggestive of acute decompensated heart failure found chest radiography sensitivity of 73% and specificity of 90%.[8] Individual findings such as peribronchial cuffing, Kerley B lines, alveolar edema, and bilateral pleural effusions are more specific than sensitive.[6]

In the JAMA Rational Clinical Examination systematic review on volume overload, intravascular congestion on chest radiography had a pooled sensitivity of 51%, specificity of 91%, positive likelihood ratio of 5.9, and negative likelihood ratio of 0.53, confirming that chest radiographic congestion is highly specific but insufficiently sensitive to exclude volume overload.[9]

Radiographic pulmonary congestion may be absent despite elevated filling pressures. Among ambulatory patients with advanced heart failure and markedly elevated pulmonary capillary wedge pressure, a substantial proportion had no radiographic congestion.[3] In mechanically ventilated ICU patients, portable chest radiography alone has limited accuracy for distinguishing hydrostatic from permeability pulmonary edema.[10]

Findings by cardiogenic shock phenotype

Shock phenotype Expected chest radiograph findings Interpretation
LV-dominant cardiogenic shock Pulmonary venous congestion, interstitial edema, alveolar edema, bilateral pleural effusions, cardiomegaly if chronic LV dysfunction is present Classic radiographic congestion pattern; acute myocardial infarction-related shock may have pulmonary edema with normal cardiac size.[11]
RV-dominant cardiogenic shock Clear lung fields, normal or mildly enlarged cardiac silhouette, possible right-sided chamber enlargement or enlarged azygous vein Clear lungs with hypotension and elevated JVP supports RV-dominant physiology; absence of edema does not exclude shock.[12][13]
Biventricular shock Pulmonary edema, pleural effusions, cardiomegaly, possible right heart enlargement May show combined left- and right-sided congestion.
Cold-dry cardiogenic shock Clear or near-normal lung fields Low-output state without overt radiographic congestion; chest radiograph may appear falsely reassuring.
Mixed cardiogenic-distributive shock Variable; pulmonary edema, diffuse bilateral opacities, ARDS pattern, pneumonia, or relatively clear lungs Bilateral opacities may represent cardiogenic edema, ARDS, pneumonia, or mixed processes; clinical and hemodynamic correlation is required.

Differential diagnostic clues

Radiographic finding Differential consideration
Widened mediastinum Aortic dissection or mediastinal hemorrhage; chest radiography cannot rule out dissection, and CT angiography is required when clinically suspected.[4]
Pneumothorax or tension pneumothorax Obstructive shock; may occur after central venous access, barotrauma, or trauma.
Focal consolidation Pneumonia with possible septic or mixed shock.
Enlarged cardiac silhouette without pulmonary edema Pericardial effusion, tamponade, cardiomyopathy, or chronic chamber enlargement; echocardiography is required for hemodynamic assessment.
Unilateral pleural effusion or hemothorax Bleeding complication, post-procedural complication, malignancy, infection, or aortic pathology.
Pulmonary artery enlargement with relative oligemia Massive pulmonary embolism with RV failure; CT pulmonary angiography is required for confirmation when suspected.
Bilateral diffuse opacities without cardiomegaly ARDS, non-cardiogenic pulmonary edema, diffuse alveolar hemorrhage, pneumonia, or mixed shock.

Device and line positioning

Chest radiography is used to confirm or screen the position of devices commonly used in cardiogenic shock. Malposition can reduce therapeutic effectiveness and cause vascular injury, hemolysis, organ ischemia, pneumothorax, or inadequate support.

Device Expected radiographic assessment Key point
Endotracheal tube Tip generally 3-5 cm above the carina Confirm after intubation and after major repositioning.
Central venous catheter Tip at the cavoatrial junction or lower superior vena cava Assess for pneumothorax after internal jugular or subclavian placement.
Pulmonary artery catheter Tip in the right or left main pulmonary artery; avoid distal migration Distal position increases risk of pulmonary artery injury or infarction.
Intra-aortic balloon pump Distal tip approximately 2 cm above the carina, corresponding to approximately 2 cm below the left subclavian artery origin; proximal end above the renal arteries. The carina is the classic radiographic landmark for IABP tip alignment. Malposition may obstruct the subclavian artery, renal arteries, or visceral branches. IABP tip malposition is independently associated with major complications.[14][15][16][17]
Left-sided Impella or other left-sided percutaneous ventricular assist device Echocardiography and fluoroscopy are preferred for precise positioning. The aortic valve location ratio, calculated as distance from carina to aortic valve divided by thoracic width, may estimate aortic valve location on supine chest radiograph; reported values are 0.25 ± 0.05 in men and 0.28 ± 0.05 in women, with good correlation with echocardiographic assessment of Impella position. Do not rely on chest radiography alone for left-sided Impella depth or inlet position. The 2022 AHA Scientific Statement on temporary mechanical circulatory support states that echocardiography is the main imaging modality for LV Impella adjustments and that Impella implanting centers should have 24-hour echocardiography access.[18][19][20]
Impella RP Pigtail should project in the left pulmonary artery with adequate distance between outflow and pulmonary valve Chest radiography is useful for right-sided percutaneous ventricular assist device position assessment.[19]
VA-ECMO cannulae Assess cannula course, gross position, migration, and kinking Worsening pulmonary edema during VA-ECMO may suggest inadequate LV unloading.[21]
Temporary pacing wires Tip commonly projects in the right ventricular apex Confirm position and assess for migration when capture changes or instability occurs.
Chest tubes and mediastinal drains Confirm intrathoracic or mediastinal course Assess for residual pneumothorax, hemothorax, or drain malposition.

Lung ultrasound as a complement

Point-of-care lung ultrasound is a useful complement to chest radiography for assessing pulmonary congestion. In a systematic review and meta-analysis of adults with symptoms suggestive of acute decompensated heart failure, lung ultrasound had higher sensitivity than chest radiography for cardiogenic pulmonary edema, with comparable specificity.[8] A subsequent meta-analysis also found higher sensitivity for lung ultrasound compared with chest radiography in acute decompensated heart failure.[22]

Lung ultrasound may be particularly useful when portable chest radiography is technically limited, when rapid bedside assessment of B-lines is needed, or when serial assessment of pulmonary congestion is required. It does not replace chest radiography for mediastinal assessment or comprehensive device-position assessment.

Serial chest radiography

Serial chest radiography should be clinically driven. It is appropriate after new device placement, with clinical deterioration, suspected device migration, suspected pneumothorax or hemothorax, worsening oxygenation, or concern for increasing pulmonary edema during mechanical circulatory support.[5] The ACR Appropriateness Criteria rate routine daily chest radiography in stable ICU patients with no change in clinical status as "controversial but may be appropriate," reflecting panel disagreement, rather than "usually appropriate."[5]

Practical chest radiograph approach

  1. Obtain a portable chest radiograph as part of the initial evaluation of suspected cardiogenic shock when it does not delay revascularization or immediate stabilization.
  2. Assess pulmonary congestion: cephalization, interstitial edema, Kerley B lines, peribronchial cuffing, alveolar edema, and pleural effusions.
  3. Assess cardiac silhouette and mediastinum.
  4. Look for alternative or coexisting diagnoses, including pneumonia, pneumothorax, aortic pathology, pericardial effusion, pulmonary embolism clues, hemothorax, or ARDS.
  5. Confirm invasive device and line position after placement and when clinical status changes.
  6. Recognize that clear lungs do not exclude cardiogenic shock, especially in RV-dominant or cold-dry shock.
  7. Use lung ultrasound, echocardiography, CT, and invasive hemodynamics when the chest radiograph is nondiagnostic or discordant with the clinical picture.

Common pitfalls

  • Assuming a normal chest radiograph excludes cardiogenic shock
  • Using chest radiography to estimate pulmonary capillary wedge pressure
  • Delaying emergent reperfusion to obtain chest radiography
  • Interpreting portable supine films as if they were upright PA films
  • Attributing all bilateral opacities to cardiogenic edema without considering ARDS, pneumonia, aspiration, or mixed shock
  • Failing to confirm intra-aortic balloon pump, pulmonary artery catheter, ECMO cannula, central venous catheter, endotracheal tube, or chest tube position
  • Misplacing the intra-aortic balloon pump tip by using the aortic knob rather than the carina as the more reliable radiographic landmark
  • Relying on chest radiography alone for left-sided Impella position instead of echocardiography or fluoroscopy
  • Overlooking clear lung fields as a clue to RV-dominant shock in inferior myocardial infarction with hypotension
  • Missing widened mediastinum, pneumothorax, hemothorax, or enlarged cardiac silhouette suggesting an alternative urgent diagnosis

References

  1. ↑ 1.0 1.1 1.2 1.3 van Diepen S, Katz JN, Albert NM; et al. (2017). "Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association". Circulation. 136 (16): e232–e268. doi:10.1161/CIR.0000000000000525.
  2. ↑ 2.0 2.1 2.2 Heidenreich PA, Bozkurt B, Aguilar D; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure". Journal of the American College of Cardiology. 79 (17): e263–e421. doi:10.1016/j.jacc.2021.12.012.
  3. ↑ 3.0 3.1 3.2 3.3 Lindow T, Quadrelli S, Ugander M (2023). "Noninvasive Imaging Methods for Quantification of Pulmonary Edema and Congestion: A Systematic Review". JACC: Cardiovascular Imaging. 16 (11): 1469–1484. doi:10.1016/j.jcmg.2023.06.023.
  4. ↑ 4.0 4.1 4.2 Gulati M, Levy PD, Mukherjee D; et al. (2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain". Journal of the American College of Cardiology. 78 (22): e187–e285. doi:10.1016/j.jacc.2021.07.053.
  5. ↑ 5.0 5.1 5.2 5.3 Laroia AT, Donnelly EF, Henry TS; et al. (2021). "ACR Appropriateness Criteria Intensive Care Unit Patients". Journal of the American College of Radiology. 18 (5S): S62–S72. doi:10.1016/j.jacr.2021.01.017.
  6. ↑ 6.0 6.1 6.2 Murphy SP, Ibrahim NE, Januzzi JL (2020). "Heart Failure With Reduced Ejection Fraction: A Review". JAMA. 324 (5): 488–504. doi:10.1001/jama.2020.10262.
  7. ↑ Roberts J, Hanneman K; et al. (2025). "ACR Appropriateness Criteria Suspected and Known Heart Failure: 2024 Update". Journal of the American College of Radiology. 22 (5S): S424–S439. doi:10.1016/j.jacr.2025.02.021.
  8. ↑ 8.0 8.1 Maw AM, Hassanin A, Ho PM; et al. (2019). "Diagnostic Accuracy of Point-of-Care Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis". JAMA Network Open. 2 (3): e190703. doi:10.1001/jamanetworkopen.2019.0703.
  9. ↑ Drum B, La Course B, Kelly M; et al. (2026). "Does This Patient Have Volume Overload?". JAMA. doi:10.1001/jama.2026.0446.
  10. ↑ Thomason JW, Ely EW, Chiles C; et al. (1998). "Appraising Pulmonary Edema Using Supine Chest Roentgenograms in Ventilated Patients". American Journal of Respiratory and Critical Care Medicine. 157 (5 Pt 1): 1600–1608. doi:10.1164/ajrccm.157.5.9708118.
  11. ↑ Samsky MD, Morrow DA, Proudfoot AG; et al. (2021). "Cardiogenic Shock After Acute Myocardial Infarction: A Review". JAMA. 326 (18): 1840–1850. doi:10.1001/jama.2021.18323.
  12. ↑ Konstam MA, Kiernan MS, Bernstein D; et al. (2018). "Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association". Circulation. 137 (20): e578–e622. doi:10.1161/CIR.0000000000000560.
  13. ↑ Kinch JW, Ryan TJ (1994). "Right Ventricular Infarction". The New England Journal of Medicine. 330 (17): 1211–1217. doi:10.1056/NEJM199404283301707.
  14. ↑ Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM (2023). "The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support". Journal of Cardiac Failure. 29 (3): 304–374. doi:10.1016/j.cardfail.2022.11.003.
  15. ↑ Bashore TM, Balter S, Barac A; et al. (2012). "2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions Expert Consensus Document on Cardiac Catheterization Laboratory Standards Update". Journal of the American College of Cardiology. 59 (24): 2221–2305. doi:10.1016/j.jacc.2012.02.010.
  16. ↑ Kim JT, Lee JR, Kim JK; et al. (2007). "The Carina as a Useful Radiographic Landmark for Positioning the Intraaortic Balloon Pump". Anesthesia and Analgesia. 105 (3): 735–738. doi:10.1213/01.ane.0000278086.23266.35.
  17. ↑ Siriwardena M, Pilbrow A, Frampton C; et al. (2015). "Complications of Intra-Aortic Balloon Pump Use: Does the Final Position of the IABP Tip Matter?". Anaesthesia and Intensive Care. 43 (1): 66–73. doi:10.1177/0310057X1504300110.
  18. ↑ Ouweneel DM, Sjauw KD, Wiegerinck EM; et al. (2016). "Assessment of Cardiac Device Position on Supine Chest Radiograph in the ICU: Introduction and Applicability of the Aortic Valve Location Ratio". Critical Care Medicine. 44 (10): e957–e963. doi:10.1097/CCM.0000000000001858.
  19. ↑ 19.0 19.1 Balthazar T, Vandenbriele C, Verbrugge FH; et al. (2021). "Managing Patients With Short-Term Mechanical Circulatory Support: JACC Review Topic of the Week". Journal of the American College of Cardiology. 77 (9): 1243–1256. doi:10.1016/j.jacc.2020.12.054.
  20. ↑ Geller BJ, Sinha SS, Kapur NK; et al. (2022). "Escalating and De-Escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association". Circulation. 146 (6): e50–e68. doi:10.1161/CIR.0000000000001076.
  21. ↑ Guglin M, Zucker MJ, Bazan VM; et al. (2019). "Venoarterial ECMO for Adults: JACC Scientific Expert Panel". Journal of the American College of Cardiology. 73 (6): 698–716. doi:10.1016/j.jacc.2018.11.038.
  22. ↑ Chiu L, Jairam MP, Chow R; et al. (2022). "Meta-Analysis of Point-of-Care Lung Ultrasonography Versus Chest Radiography in Adults With Symptoms of Acute Decompensated Heart Failure". The American Journal of Cardiology. 174: 89–95. doi:10.1016/j.amjcard.2022.03.022.
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