Levine’s sign
Levine’s sign is a descriptive chest-pain gesture in which patients hold a clenched fist over the sternum while describing discomfort consistent with ischemic chest pain.[1] The clinical significance of Levine’s sign is limited diagnostic utility for ruling in or ruling out acute coronary syndrome because test characteristics are poor.[1] Presence of the gesture should prompt standard chest-pain evaluation rather than replace objective assessment with electrocardiography and cardiac troponin testing.[2]
Clinical definition
Levine’s sign is defined as a clenched fist held over the sternal area when patients describe chest discomfort.[1]
Diagnostic value in chest-pain evaluation
Levine’s sign is associated with ischemic chest discomfort but demonstrates poor sensitivity for ischemic causes of chest pain.[1] In a prospective observational study of 202 patients admitted with chest discomfort, none of the examined gestures (including Levine’s sign) had sensitivity exceeding 38%.[1] Levine’s sign specificity for ischemic disease was reported in the range of 78% to 86% in the same study.[1] Positive predictive value for Levine’s sign did not exceed 55%, limiting its usefulness for confirming ischemia.[1]
Clinical significance by interpretation
Levine’s sign should be interpreted as a weak predictor rather than a diagnostic criterion because a substantial proportion of ischemic presentations do not exhibit the gesture.[1] Levine’s sign can modestly increase suspicion for ischemic etiology, but it does not provide sufficient discrimination to omit guideline-recommended ACS evaluation.[1]
Integration with guideline-recommended acute evaluation
Cardiac troponin testing is the preferred biomarker strategy for detecting myocardial injury in acute chest pain evaluation, with serial assessment recommended.[2] High-sensitivity cardiac troponin is preferred because it allows more rapid detection of myocardial injury with increased diagnostic accuracy.[2] The presence of Levine’s sign does not substitute for biomarker-based assessment and electrocardiography in acute chest-pain pathways.[2]
Key evidence supporting these conclusions
In the prospective observational study assessing patient gestures, Levine’s sign specificity ranged from 78% to 86% for evidence of ischemic disease.[1] In the same study, sensitivity for Levine’s sign remained low, with sensitivities for all evaluated gestures not exceeding 38%.[1] In the same study, positive predictive value for Levine’s sign did not exceed 55%, supporting the conclusion that the gesture has limited confirmatory value.[1]
Practical clinical implications
Levine’s sign should be used only as part of the overall clinical assessment of chest discomfort rather than as a standalone diagnostic test.[1] Objective evaluation with ECG and serial high-sensitivity troponin should proceed regardless of whether Levine’s sign is present.[2]
Targets and goals of therapy
The evaluation goal in suspected ACS is identification of myocardial injury using guideline-recommended biomarker testing rather than reliance on bedside physical signs.[2]