Comment on: Jain CC, Tschirren J, Reddy YNV, Melenovsky V, Redfield M, Borlaug BA. Subclinical Pulmonary Congestion and Abnormal Hemodynamics in Heart Failure With Preserved Ejection Fraction. JACC Cardiovasc Imaging. 2022 Apr;15(4):629-637. doi: 10.1016/j.jcmg.2021.09.017. Epub 2021 Nov 17. PMID: 34801461; PMCID: PMC8995316.

Purpose: To determine the accuracy of quantitative CT to diagnose pulmonary edema compared to qualitative CT and CXR and to determine a threshold Hounsfield unit (HU) measurement for pulmonary edema on CT examinations. Method: Electronic medical records were searched for patients with a billing diagnosis of heart failure and a Chest CT and CXR performed within three hours between 1/1/2016 to 10/1/2016, yielding 100 patients. CXR and CT examinations were scored for the presence and severity of edema, using a 0-5 scale, and CT HU measurements were obtained in each lobe. Polyserial correlation coefficients evaluated the association between CT HUs and CXR scores, and receiver operating characteristic (ROC) curve analysis determined a cutoff CT HU value for identification of pulmonary edema. Results: Correlation between CT HU and CXR score was moderately strong (r=0.585-0.685) with CT HU measurements demonstrating good to excellent accuracy in differentiating between no edema (grade 0) and mild to severe edema (grades 1-5) in every lobe, with AUCs ranging between 0.869 and 0.995. The left upper lobe demonstrated the highest accuracy, using a cutoff value of -825 HU (AUC of 0.995, sensitivity=100 % and specificity=95.1 %). Additionally, qualitative CT evaluation was less sensitive (84 %) than portable CXR in identifying pulmonary edema. However, quantitative CT evaluation was as sensitive as portable CXR (100 %) and highly specific (95 %). Conclusions: Quantitative CT enables the identification of pulmonary edema with high accuracy and demonstrates a greater sensitivity than qualitative CT in assessment of pulmonary edema.