To compare the visibility of anatomic structures in direct-detector chest radiographs acquired with different tube voltages at equal effective doses to the patient.The study protocol was approved by the institutional internal review board, and written informed consent was obtained from all patients. Posteroanterior chest radiographs of 48 consecutively selected patients were obtained at 90, 121, and 150 kVp by using a flat-panel-detector unit that was based on cesium iodide technology and automated exposure control. Monte Carlo simulations were used to verify that the effective dose for all kilovoltage settings was equal. Five radiologists subjectively and independently rated the delineation of anatomic structures on hard-copy images by using a five-point scale. They also ranked image quality in a blinded side-by-side comparison. Average ranking scores were compared by using one-way analysis of variance with repeated measures. Data were analyzed for the entire patient group and for two patient subgroups that were formed according to body mass index (BMI).The visibility scores of most anatomic structures were significantly superior with the 90-kVp images (mean score, 3.11), followed by the 121-kVp (mean score, 2.95) and 150-kVp images (mean score, 2.80). Differences did not reach significance (P > .05) only for the delineation of the peripheral vessels, the heart contours, and the carina. This was also true for the subgroup of patients (n = 24) with a BMI greater than and the subgroup of patients (n = 24) with a BMI less than the mean BMI (26.9 kg/m(2)). At side-by-side comparison, the readers rated 90-kVp images as having superior image quality in the majority of image triplets; the percentage of 90-kVp images rated as "first choice" ranged from 60% (29 of 48 patients) to 90% (43 of 48 patients), with a median of 88% (42 of 48 patients), among the readers.Delineation of most anatomic structures and overall image quality were ranked superior in digital radiographs acquired with lower kilovoltage at a constant effective patient dose.