Cardiac chest pain: does body language help the diagnosis?
BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7021.1660 (Published 23 December 1995) Cite this as: BMJ 1995;311:1660
The pain of cardiac ischaemia is characteristically crushing, gripping, or tight in nature. When describing their chest pain many patients will use movements of the hands to illustrate their symptoms. A clenched fist to the centre of the sternum conveys the gripping quality of the pain (Levine's sign; fig 1) while a flat hand describes the sensation of crushing heaviness (fig 2).1 Tight band-like chest pain may be represented by a movement of the palmar surfaces of both hands laterally from the centre of the chest (fig 3). Patients with non-cardiac pain may use other actions to illustrate their pain, such as movement of the fingertips up and down the sternum (oesophageal pain) or pointing to one spot (chest wall pain).
Levine's sign: clenched fist to middle of chest
Both hands placed flat in middle of chest and drawn outwards
In response to the request “show me where your pain is and tell me what it feels like” virtually all the patients I have seen used their hands not only to show the location of the pain but also to convey its quality. It is often assumed that Levine's sign and its variants are good markers for ischaemic cardiac pain but their value has not been assessed objectively. This study aimed to measure the sensitivity, specificity, and predictive value of these signs in patients admitted to the coronary care unit with chest pain.
Patients, methods, and results
During their initial clerking patients admitted to the coronary care unit with chest pain were asked to “show me where your pain is and tell me what it feels like.” The admitting doctor recorded the response on an illustrated form, choosing from three designated responses (clenched fist to the centre of the sternum; flat hand to the centre of the sternum; both flat hands drawn from the centre of the chest outwards) or describing some other action and drawing it on the form. The forms were collated and stored for at least one year after admission to allow time for any investigations such as exercise electrocardiography, cardiac perfusion scanning, coronary angiography, and upper gastrointestinal endoscopy to be completed. The forms were kept by an independent observer while the case notes were examined without knowledge of each patient's chest pain response. Each case was classified as cardiac, non-cardiac, or uncertain. When all the notes had been examined the final clinical classification for each was matched to the original chest pain response.
Hand movements made by patients in response to a request to “show me where your pain is and tell me what it feels like”
The notes of 203 consecutive patients admitted during a six month period in 1992-3 were examined. The cause of the chest pain was considered to be cardiac in 138 (68%), non-cardiac in 21, and uncertain in 44 (most of these patients had coexisting cardiac ischaemia and gastro-oesophageal disease). Of the patients with cardiac pain, 110 (80%) used the designated hand movements to describe their pain, but only 33 (51%) of those with non-cardiac or pain of uncertain origin did so (2=17.8, P<0.01). Only 19 (14%) patients with cardiac pain displayed the true Levine's sign compared with 64 (46%) who placed the flat of the hand on their chest while describing their pain and 27 (20%) who drew both hands outwards (table).
Although the sensitivity of the designated hand movements for cardiac pain was high (80%), the specificity was low (49%). This gave a positive predictive value of 77% and a negative predictive value of 53%.
Comment
This study has shown that if patients admitted to a coronary care unit illustrate the nature of their chest pain by placing a clenched fist or a flat hand on the sternum, or by drawing both palms laterally across their chest, there is a 77% chance that their pain is due to cardiac ischaemia. If they do not use these signs there is an even chance that their pain is non-ischaemic. These signs are not discriminatory, but a positive response lends support to a diagnosis of cardiac ischaemia.
I am most grateful to Dr Liz Mather and Dr Paul Kemp for their help with this study.