Findings on chest x-ray are the same for older and younger patients with congestive heart failure, but chest x-ray interpretation is often difficult in older persons.

Adequate chest x-rays are often difficult to obtain in older patients because of their fatigue or frailty. Older people may have difficulty taking in and holding a deep breath or even holding their head up.

Older people often have kyphoscoliosis and chronic pulmonary disease, abnormalities which may make interpretation of the chest x-ray difficult. Don't dispair! Insist on obtaining a good chest x-ray, and find a good radiologist to help you interpret it!

Classic finding of congestive heart failure on chest x-ray:

• Increased heart size -- cardiothoracic ratio >0.50.
  Note: in some series older women without heart disease may have cardiothoracic ratios slightly greater than 0.50.
• Large hila with indistinct margins
• Prominence of superior pulmonary veins; cephalization of flow
• Fluid in interlobar fissures
• Pleural effusion
• Kerley B lines
• Alveolar edema
• Peribronchial cuffing

It is often difficult to obtain a satisfactory chest film of an elderly person because of frailty or because of their inability to cooperate fully with the x-ray technician. Further, difficulties in interpretation abound, not only because of problems just noted regarding obtaining a satisfactory full inspiratory film, but also because of the frequent association of coexistent pulmonary fibrosis and kyphoscoliosis. Nevertheless, persistence in working with the radiologists in obtaining readable films will often pay rich diagnostic dividends. Try to obtain a film decent enough to see the lung markings, but do not wear the patient out by trying to get a perfect x-ray.

This radiograph shows classic findings of congestive heart failure in an elderly patient. Please note the enlarged heart, large indistinct hila, increased prominence of the pulmonary veins draining the upper lobes ("reversal of flow"), and the bilateral alveolar pulmonary edema.