William Herring, M.D.

© 2003

Recognizing
Cardiomegaly

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 One of the easiest
Cardio-thoracic observations to make is the
Ratio 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 x-

ray 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 patient’s 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, it’s 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
Congratulations, You Graduate

I know a
big heart
when I see
it

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