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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 hours of admission after acute myocardial infarction were related to early (30 days) and late (6 months, 1 year) mortality. The chest films were divided into four degrees of pulmonary venous congestion: grade 0 — no pulmonary congestion (n = 141); grade 1 redistribution of pulmonary blood flow (n = 38); grade II interstitial pulmonary edema (n = 61); grade III localized alveolar edema (n = 20); grade IV — diffuse alveolar edema (n = 13). In the absence of pulmonary congestion, 94% of the patients survived the first month and 88% of them survived 1 year; when the heart size was also normal, more than 96% of patients survived 1 month and more than 91% survived 1 year. The 30-day mortality was significantly (p < 0.005) higher with grades II, III and IV pulmonary venous congestion than with grade 0, and 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 less than 50% of the patients were alive after 1 year. With grade IV, only 18% of patients survived after 30 days and none after 1 year. Without pulmonary venous congestion, 24% of patients with increased initial left-heart dimension (> 50 mm/m2) and increased cardiothoracic ratio (> 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. Thus, 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 first month or the first year after the acute event.

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