Levine’s Sign Points to Spontaneous Coronary Artery Dissection in a Healthy Young Male

Abstract

Levine’s sign is a universal sign of ischemic chest pain, defined as an individual holding a clenched fist over the chest that has a low sensitivity but is relatively specific for ischemia. Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic and a very unusual cause of acute myocardial infarction.In literature, it has been more common in young women, postpartum, or with fibromuscular dysplasia. Strenuous exercise is a rare cause of SCAD. We describe a case of a healthy 46-year-old Hispanic male who presented to ER after his morning gym session. The initial EKG was unremarkable. However, due to Levine's sign, a repeat EKG was done and showed hyperacute T waves with J-point elevation in the anterior leads. An immediate coronary angiogram revealed a spontaneous coronary artery dissection in the mid-left anterior descending artery (LAD) segment. Given the resolution of the chest pain and thrombolysis in myocardial infarction (TIMI) 3 flow, no intervention was done. The patient was managed medically with an uneventful recovery. In the current times, with the advent of high sensitivity troponin along with other rapid multimodality imaging techniques, the importance of physical signs and symptoms like Levine's sign has diminished. Yet, they still remain a vital part of patient evaluation. Additionally, SCAD is uncommon in males. However, this patient was consuming energy booster powder that may have predisposed him to the SCAD. In our opinion, Levine's sign still has high clinical value in the right context. We also postulate that energy booster supplements may have serious deleterious cardiovascular effects, and large studies are necessary to understand their full effects on the cardiovascular system.