Levine’s Sign


Other Known AliasesPalm Sign, Cossio’s Sign, Cossio-Levine’s Sign

DefinitionClenched fist held over the sternum while a patient is describing their chest pain and classically is the right hand, as cardiac pain can refer to the left arm.

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Clinical SignificanceThere is very little significance to this sign and has been studied to only have a 14% sensitivity for cardiac chest pain, but is a classic physical exam finding and frequent pimp fodder.

History – Named after Samuel Albert Levine (1891-1966), who was an American cardiologist and attending physician at The Brigham Hospital in Boston, MA, and assistant professor of medicine at Harvard University.  He graduated Harvard at the age of 20 and was the first physician to diagnose President Franklin Roosevelt with poliomyelitis.  He was a pioneer in coronary thrombosis research and was the second physician to ever diagnose the condition, which he described it in his classic book Clinical Heart Disease in 1936. 

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He is also the namesake of The Levine Scale, a 1 to 6 grading system to characterize the intensity  of heart murmurs, and Lown-Ganong-Levine syndrome, which is a pre-excitation syndrome causing a shortened PR interval with normal QRS complexes in tachycardia.

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The Levine Scale

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Lown-Ganong-Levine Syndrome



  5. Edmondstone WM. Cardiac chest pain: does body language help the diagnosis? BMJ. 1995;311(7021):1660-1. [pubmed]
  6. Levine HJ.  Profiles in Cardiology: Samuel A. Levine (1891-1966).  Clin Cardiol.  1992;15:473-476
  7. Bedford DE. Samuel Albert Levine (1891-1966). British heart journal. 1966; 28(6):853-4. [pubmed]
  8. Silverman ME, Wooley CF. Samuel A. Levine and the history of grading systolic murmurs. The American journal of cardiology. 2008; 102(8):1107-10. [pubmed]
  9. Lown B, Ganong WF, Levine SA. The syndrome of short P-R interval, normal QRS complex and paroxysmal rapid heart action. Circulation. 1952; 5(5):693-706. [pubmed]

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