Limitations of cardiothoracic ratio derived from chest radiographs to predict real heart size: comparison with magnetic resonance imaging

BACKGROUND: Cardiothoracic ratio (CTR) in chest radiographs is still widely used to estimate cardiac size despite the advent of newer imaging techniques. We hypothesise that a universal CTR cut-off value of 50% is a poor indicator of cardiac enlargement. Our aim was to compare CTR with volumetric and functional parameters derived from cardiac magnetic resonance imaging (MRI). METHODS: 309 patients with a chest radiograph and cardiac MRI acquired within a month were reviewed to assess how CTR correlates with multiple cardiac MRI variables: bi-ventricular EDV (absolute and indexed to body surface area), EF, indexed total heart volume and bi-atrial areas. In addition, we have also determined CTR accuracy by creating multiple ROC curves with the described variables. RESULTS: All cardiac MRI variables correlate weakly but statistically significantly with CTR. This weak correlation is explained by a substantial overlap of cardiac MRI parameters in patients with normal and increased CTR. For all variables, CTR was only mildly to moderately better than a chance to discriminate cardiac enlargement (AUC 0.6–0.7). Large CTR values (> 55%) are specific but not sensitive, while low CTR values (< 45%) are sensitive but not specific. Values in between are not sensitive nor specific. CONCLUSIONS: CTR correlates weakly with true chamber size assessed by gold standard cardiac MRI and has a weak discriminatory power. Thus, clinical decisions based on intermediate CTRs (45–55%) should be avoided. Large CTRs (> 55%) are likely indicative of true heart chamber enlargement. Low CTRs (< 45%) are likely indicative of normal heart size. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13244-021-01097-0.