In contrast to the results of three meta-analyses [7–9], RV/LV diameter ratio assessed by CTPA was not associated with mortality in our prospective cohort. Overall, only 8 of 39 studies included in these meta-analyses were prospective and according to a meta-regression analysis, the risk estimates derived from retrospective studies were significantly higher than the estimates from the prospective studies . Moreover, patients in all prospective studies that demonstrated an association between RV/LV diameter ratio and mortality were younger than the patients enrolled in our cohort (mean age 54–67 versus 75.4 years) [17, 31, 32]. Because co-morbid conditions as well as ageing itself may lead to left ventricular enlargement or right ventricle dilatation, the prognostic accuracy of RV/LV diameter ratio may be lower in elderly multimorbid patients. Indeed, the largest prospective cohort including 848 mostly elderly patients (median age 72 years) did not demonstrate an association between RV/LV diameter ratio and mortality .