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We fully agree with Dr Jolobe that radiographic stigmata of acute heart failure are important in the diagnosis of patients with acute dyspnoea. Obviously, chest X-ray had an integral part in the diagnosis and management of patients in both groups in the BASEL study [1]. However, it is important to point out three details. First, chest X-ray is only moderately accurate in the diagnosis of acute heart failure [2, 3]. Radiographic findings of acute heart failure are specific, but only moderately sensitive [2, 3]. Secondly, B-type natriuretic peptide (BNP) levels provide complementary diagnostic information to the clinical investigation and chest X-ray [2]. BNP levels >100 pg mL−1 contribute significantly to the prediction of heart failure over each of the radiographic indicators [2]. Thirdly, when used in conjunction with the clinical evaluation and chest X-ray, the use of BNP levels improves the management of patients with acute dyspnoea [1].

Although the clinical and radiographic response to diuretic and vasodilator therapy can at times be very helpful in the diagnosis, this ‘try and error’ strategy seems to be only a second-line approach to me.

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