Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) are commonly first evaluated in primary care, where early identification of patients at risk of deterioration is essential. The pulmonary artery–ascending aorta (PA/A) ratio on chest CT has been proposed as a non-invasive marker of pulmonary hypertension and adverse outcomes in stable COPD, but its relevance during exacerbations and its importance for general practice remain unclear.To assess the inter-observer variability of PA/A ratio values and their associations to clinically relevant outcomes in patients hospitalized with AE-COPD.We performed a retrospective study of adults hospitalized with a primary diagnosis of AE-COPD who underwent chest CT during hospitalization between 1 January 2020 and 31 March 2025. Two independent observers measured the PA/A ratio using standardized anatomical landmarks, and the mean of their measurements was used to categorize patients into two groups using the established cut-off of PA/A >1. Outcomes included length of hospital stay, need for non-invasive ventilation (NIV), and antibiotic treatment. Statistical analyses included Bland–Altman comparison, t-tests, and Fisher’s exact tests.Of 174 patients screened, 35 met inclusion and exclusion criteria (16 males/19 females, mean age: 68.8 ± 8.4 years). All patients were treated with systemic corticosteroids. Interobserver analysis showed good agreement (bias: –0.01, 95% limits of agreement: –0.15 to 0.12) and no systematic difference was found (p=0.32). 20 patients had a mean PA/A ≤1 and 15 patients showed PA/A >1. Length of hospital stay did not differ between groups (10.9 vs 11.3 days, p=0.83) and antibiotic rates were comparable (65% vs 73%, p=0.72). However, NIV use was significantly higher in the >1 group (25% vs 67%, p=0.02).A PA/A ratio >1 was strongly associated with an increased need for NIV, suggesting value as an early indicator of exacerbation severity. For primary care clinicians, familiarity with this parameter may support triage decisions and improve interpretation of radiology reports from referrals.PA/A ratio is a reproducible measurement and may help identify AE-COPD patients at higher risk of requiring respiratory support. Prospective studies in community-managed COPD populations are warranted to explore its role in guiding referral urgency and follow-up in primary care.