The initial chest x-ray in acute myocardial infarction. Prediction of early and late mortality and survival.

Abstract

To evaluate the importance of the initial chest X-ray in predicting mortality and survival after acute myocardial infarction, the degree of pulmonary congestion, cardiothoracic ratio and left-heart dimension on the initial chest X-ray obtained from 273 patients within 24 h of admission after acute myocardial infarction were related to early (30 days) and late (6 mo., 1 yr) mortality. The chest films were divided into 4 degrees of pulmonary venous congestion: grade 0, no pulmonary congestion (no. = 141); grade 1, redistribution of pulmonary blood flow (no. = 38); grade II, interstitial pulmonary edema (no. = 61); grade III, localized alveolar edema (no. = 20); and grade IV, diffuse alveolar edema (no. = 13). In the absence of pulmonary congestion, 94% of the patients survived the 1st month and 88% of them survived 1 yr; when the heart size was also normal, 96% of patients survived 1 mo. and > 91% survived 1 yr. The 30 day mortality was significantly (P < 0.005) higher with grades II, III and IV pulmonary venous congestion than with grade 0; late mortalities increased significantly (P < 0.005) with any degree of pulmonary venous congestion compared with grade 0. Mortalities with grades II and III congestion were similar and < 50% of the patients were alive after 1 yr. With grade IV only 18% of patients survived after 30 days and none after 1 yr. Without pulmonary venous congestion 24% of patients with increased initial left-heart dimension (.gtoreq. 50 mm/m2) and increased cardiothoracic ratio (.gtoreq. 0.50) died during the subsequent year, compared with only 6% of patients with normal initial heart dimension and 9% with normal initial cardiothoracic ratio. Early and late mortality in patients without pulmonary venous congestion was significantly lower (P < 0.01) than in patients with any degree of pulmonary venous congestion, regardless of left-heart dimension or cardiothoracic ratio. The degree of congestion and left-heart size on the initial chest X-ray after acute myocardial infarction are highly useful for defining groups with increased risk of dying or surviving within the 1st mo. or the 1st yr after the acute event.