title: Standardized evaluation of lung congestion during COPD exacerbation better identifies patients at risk of dying.
abstract: BACKGROUND
  Congestive heart failure is underdiagnosed in patients with chronic obstructive pulmonary disease (COPD). Pulmonary congestion on chest radiograph at admission for acute exacerbation of COPD (AECOPD) is associated with an increased risk of mortality. A standardized evaluation of chest radiographs may enhance prognostic accuracy.
  
  
  OBJECTIVE
  We aimed to evaluate whether a standardized, liberal assessment of pulmonary congestion is superior to the routine assessment in identifying patients at increased risk of long-term mortality, and to investigate the association of heart failure with N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentrations.
  
  
  METHODS
  This was a prospective cohort study of 99 patients admitted for AECOPD. Chest radiographs obtained on admission were routinely evaluated and then later evaluated by blinded investigators using a standardized protocol looking for Kerley B lines, enlarged vessels in the lung apex, perihilar cuffing, peribronchial haze, and interstitial or alveolar edema, defining the presence of pulmonary congestion. Adjusted associations with long-term mortality and NT-proBNP concentration were calculated.
  
  
  RESULTS
  The standardized assessment was positive for pulmonary congestion in 32 of the 195 radiographs (16%) ruled negative in the routine assessment. The standardized assessment was superior in predicting death during a median follow up of 1.9 years (P=0.022), and in multivariable analysis, only the standardized assessment showed a significant association with mortality (hazard ratio 2.4, 95% confidence interval [CI] 1.2-4.7) (P=0.016) and NT-proBNP (relative concentration 1.8, CI 1.2-2.6) (P=0.003).
  
  
  CONCLUSIONS
  By applying a standardized approach when evaluating pulmonary congestion on chest radiographs during AECOPD, a group of patients with increased risk of dying, possibly due to heart failure, is identified.
authors.affiliation: Cardiothoracic Research Group, Division of Medicine, Akershus University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
authors.forename: Arne Didrik
authors.initials: AD
authors.lastname: Høiseth
authors.affiliation: Cardiothoracic Research Group, Division of Medicine, Akershus University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
authors.forename: Torbjørn
authors.initials: T
authors.lastname: Omland
authors.affiliation: Department of Radiology, Akershus University Hospital, Lørenskog, Norway.
authors.forename: Bo Daniel
authors.initials: BD
authors.lastname: Karlsson
authors.affiliation: Cardiothoracic Research Group, Division of Medicine, Akershus University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
authors.forename: Pål H
authors.initials: PH
authors.lastname: Brekke
authors.affiliation: Cardiothoracic Research Group, Division of Medicine, Akershus University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
authors.forename: Vidar
authors.initials: V
authors.lastname: Søyseth
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D015897:Comorbidity; D018450:Disease Progression; D006333:Heart Failure / Q000097:blood / Q000150:complications / Q000175:diagnosis* / Q000401:mortality; D006801:Humans; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000097:blood; D010446:Peptide Fragments / Q000097:blood; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications / Q000175:diagnosis* / Q000401:mortality; D011654:Pulmonary Edema / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality; D011859:Radiography; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain
keywords: NT-proBNP; X-ray; cephalization; heart failure; mortality; radiograph