Body language and diagnosis of ischemic /non-ischemic chest pain
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 A) while a flat hand describes the sensation of crushing heaviness (fig B). 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 C).
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). 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.
Prevalences of the Levine, Palm, Arm, and Pointing Signs were 11%, 35%, 16%, and 4%, respectively. Using troponin levels and results of functional studies and coronary angiograms as reference standards, none of the sensitivities of the signs exceeded 38%. Specificities of the Levine and Arm Signs ranged between 78% and 86%, but the positive predictive values did not exceed 55%. The Pointing Sign had a specificity of 98% for evidence of nonischemic chest discomfort, and the positive predictive value of a negative troponin was 88%. The diameter of discomfort significantly correlated with certain gestures. Larger chest pain diameters were associated with evidence of myocardial ischemia.
Although certain gestures are exhibited by patients presenting with chest discomfort, they generally have poor test characteristics. The Pointing Sign has a high specificity for nonischemic chest discomfort, but a low prevalence. The gestures may communicate the size of the chest discomfort, with larger areas suggestive of ischemia.