Contrast-enhanced chest computed tomography in acute heart failure: a narrative review of imaging clues to precipitating factors and underlying cardiac disease

Acute heart failure (AHF) is a clinical syndrome characterized by the rapid onset or worsening of symptoms and signs resulting from structural or functional cardiac abnormalities and may present with systemic congestion, hypoperfusion, or cardiogenic shock. AHF can be divided into de novo AHF (i.e., new onset) and acute decompensated heart failure (i.e., rapid clinical deterioration in patients with a previous diagnosis of heart failure) and can be caused by various precipitating factors (e.g., acute myocardial infarction, nonadherence to heart failure medications, high salt intake, arrhythmia, and hypertensive crisis). AHF is often diagnosed based on the symptoms and signs of heart failure, supported by elevated serum levels of N-terminal pro-B-type natriuretic peptide and chest radiographic and echocardiographic abnormalities. Contrast-enhanced chest computed tomography (CT) is not routinely used for the diagnostic workup of AHF. However, CT is increasingly used in patients with indeterminate clinical presentations in the emergency department (ED) to discriminate AHF from multifocal pneumonia or acute respiratory distress syndrome. In this context, CT may be the initial imaging tool for patients with AHF who present to the ED. Owing to advances in CT technology, careful assessment of routine chest CT findings may help determine the specific etiology of AHF, especially new-onset AHF. This review provides important tips for identifying diagnostic clues of AHF based on CT findings.