Clenched fist sign is a gestural indicator used by patients to localize or describe the quality of chest pain, most commonly associated with angina pectoris. The patient instinctively places a fist against the chest, usually over the substernal region, to convey the constricting, oppressive, or squeezing nature of the discomfort. This nonverbal cue can assist clinicians in identifying cardiac ischemia.

Pathophysiology

• Angina pectoris arises from myocardial ischemia, leading to chest discomfort or pain.

• The pain is typically retrosternal, with a pressure-like or constricting sensation.

• The clenched fist gesture reflects the patient’s perception of constriction and severity of ischemic pain.

• The sign does not have a direct physiologic mechanism but is a behavioral expression of visceral discomfort that correlates with cardiac pathology.

Examination Technique

Patient Observation

• Ask the patient to point to or describe the location of their chest pain.

• Observe whether the patient places a clenched fist over the chest, particularly the substernal region.

Assessment

• Note the hand used, position on the chest, and any associated facial expressions.

• Correlate the gesture with reported pain characteristics such as squeezing, pressure, or tightness.

• Document timing, duration, and triggers (e.g., exertion, emotional stress).

Clinical utility

• Indicative of angina pectoris: Often performed instinctively to express substernal constrictive pain.

• Supports cardiac evaluation: Useful when patients cannot articulate pain clearly, such as in the elderly, children, or nonverbal patients.

• Adjunct to history-taking: Enhances understanding of pain quality, location, and severity.

• Noninvasive marker: Helps distinguish ischemic pain from musculoskeletal or pleuritic pain, though not definitive.

Differential Diagnosis

Pediatric considerations

• Children may point, press, or make similar gestures instead of verbalizing chest discomfort.

• Observing nonverbal cues can assist in identifying potential cardiac or thoracic pain.

Geriatric considerations

• Older adults may have atypical angina presentations with minimal pain.

• Clenched fist sign can serve as a helpful nonverbal indicator when verbal description is limited.

Limitations

• Not pathognomonic; non-cardiac pain may elicit similar gestures.

• Subjective interpretation; must be correlated with history, physical examination, and investigations.

• Absence of the sign does not exclude cardiac ischemia.

Patient Counseling

• Explain that the gesture is a common way to express chest discomfort.

• Encourage patients to report any chest pain promptly and describe associated symptoms.

• Discuss the importance of further cardiac evaluation including ECG, stress testing, or biomarker analysis.

Conclusion

Clenched fist sign is a classic nonverbal indicator of angina pectoris, reflecting the constrictive nature of myocardial ischemia. While it is not definitive for diagnosis, recognition of this gesture enhances clinical assessment, patient communication, and early identification of cardiac conditions.

References

1. Braunwald E. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia: Elsevier; 2022.

2. McPhee SJ, Papadakis MA. Current Medical Diagnosis and Treatment 2023. New York: McGraw-Hill; 2023.

3. Amsterdam EA, et al. Chest Pain Evaluation in Adults: ACC/AHA Guidelines. Circulation. 2010;122:e266–e325.

4. Cohn PF, et al. Nonverbal Indicators of Cardiac Pain: Clinical Observations. J Am Coll Cardiol. 1983;2:1059–1064.

5. Goldman L, Schafer AI. Goldman-Cecil Medicine. 26th ed. Philadelphia: Elsevier; 2020.