General

Clinical Question:
Are typical hand gestures made by patients with acute chest pain useful for ruling in or ruling out ischemia?

Bottom Line:
Gestures to signal chest pain are not particularly helpful in distinguishing acute ischemia from other causes. Approximately half the patients who exhibit classic gestures -- clenched fist or open palm on chest, or grabbing the left upper arm -- will actually have either myocardial ischemia or infarction. Two of 3 patients who point with 1 or 2 fingers to an area on their chest will not have ischemia. (LOE = 3b)

Reference:
Marcus GM, Cohen J, Varosy PD, et al. The utility of gestures in patients with chest discomfort. Am J Med 2007;120:83-89.  [PMID:17208083]

Study Design:
Cohort (prospective)

Setting:
Inpatient (any location)

Synopsis:
Cardiologists conducting this study enrolled a convenience sample of 202 English-speaking patients admitted to 3 hospitals with a chief complaint of chest pain. Patients with renal failure were excluded. All patients were asked to describe their chest pain, show where the pain was, and show what the pain felt like. Observers looked for gestures associated with the description of the pain: the Levine sign, a clenched fist brought to the chest; the palm sign, a hand brought to the chest with outstretched fingers and the palm resting on the chest; the arm sign, the left arm touched with the right hand; or the pointing sign, 1 or 2 fingers pointing to a specific point on the chest. The gold standards used to verify the diagnosis of myocardial ischemia or infarction were 24-hour troponin I levels; a coronary angiography showing at least 70% stenosis of one major vessel; or the outcomes of functional studies, either exercise or pharmacologic stress testing. Using troponin levels as the gold standard, myocardial infarction occurred in 21% of patients, with 7.4% having ST-segment elevated myocardial infarction confirmed by angiography. The design of the study was not optimal. The inverviews were conducted approximately 1 day following the onset of chest pain. Ideally, the study would have been conducted at first contact with patients with new-onset chest pain before healthcare personnel had the chance to suggest the gestures or to prompt the patients for symptoms. Also, the researchers were able to pick and choose who they enrolled, and these results may not have been the same had they enrolled consecutive patients. Slightly more than 20% of patients were unable to specify their chest pain and only 53% of the patients exhibited any of the signs. Only 11% exhibited the classic clenched fist (Levine) sign. The positive predictive value, using the criterion of abnormal troponin levels or a positive diagnostic test, was 50% (95% CI, 27% - 73%) and the negative predictive value was 31% (28%-44%). Values were similar for the arm sign. The palm sign was more predictive of ischemia, if present (positive predictive value = 65%; 52%-77%). The pointing sign signalled no ischemia, with a positive predictive value for negative troponin levels of 67% (22%-96%).