From the Guidelines
The SOCRATES criteria for chest pain of cardiac origin typically include retrosternal chest discomfort, gradual onset, pressure or heaviness character, radiation to the left arm or jaw, associations with shortness of breath or nausea, a time course of minutes to hours, exacerbation with exertion, and relief with rest or nitroglycerin, with a severity that is moderate to severe. The characteristics of chest pain can be broken down into several key components:
- Site: The pain is usually retrosternal (behind the breastbone) or precordial (left chest), often described as central chest pain 1.
- Onset: Cardiac pain typically develops gradually, building over minutes rather than instantaneously, as sudden onset of ripping chest pain is unlikely to be anginal and is suspicious of an acute aortic syndrome 1.
- Character: The pain is commonly described as pressure, heaviness, squeezing, tightness, or crushing rather than sharp or stabbing, with anginal symptoms perceived as retrosternal chest discomfort 1.
- Radiation: The pain frequently radiates to the left arm, jaw, neck, back, or both arms, but pain radiating to below the umbilicus or hip is unlikely related to myocardial ischemia 1.
- Associations: Associated symptoms include shortness of breath, nausea, vomiting, sweating, lightheadedness, and anxiety, with common symptoms associated with myocardial ischemia including dyspnea, palpitations, diaphoresis, and upper abdominal pain 1.
- Time course: Cardiac chest pain typically lasts minutes to hours, not seconds or days, and may be persistent rather than fleeting, as fleeting chest pain is unlikely to be related to ischemic heart disease 1.
- Exacerbating/relieving factors: The pain often worsens with exertion and improves with rest, but relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia and should not be used as a diagnostic criterion 1.
- Severity: Cardiac pain is usually moderate to severe and may be described as distressing or frightening, with ripping chest pain being suspicious of an acute aortic syndrome 1. These characteristics help differentiate cardiac chest pain from other causes, though atypical presentations are common, especially in women, elderly patients, and those with diabetes, and prompt recognition of these features is crucial as they may indicate serious conditions like myocardial infarction or unstable angina requiring immediate medical attention.
From the Research
Typical SOCRATES Criteria for Chest Pain of Cardiac Origin
The SOCRATES criteria are used to evaluate chest pain and determine its origin. The criteria include:
- Site: The location of the chest pain, which can be retrosternal, precordial, or radiate to the arms, neck, or jaw 2, 3, 4
- Onset: The time of onset of the chest pain, which can be sudden or gradual 2, 3, 4
- Character: The description of the chest pain, which can be pressure, tightness, or heaviness 2, 3, 4
- Radiation: The radiation of the chest pain to other areas, such as the arms, neck, or jaw 2, 3, 4
- Associations: The presence of associated symptoms, such as shortness of breath, nausea, or vomiting 2, 3, 4
- Time course: The duration of the chest pain, which can be constant or intermittent 2, 3, 4
- Exacerbating/relieving factors: The factors that exacerbate or relieve the chest pain, such as movement or rest 2, 3, 4
- Severity: The severity of the chest pain, which can be mild, moderate, or severe 2, 3, 4
Evaluation of Chest Pain
The evaluation of chest pain involves a systematic approach, including:
- History and physical examination 2, 3, 4
- Electrocardiogram (ECG) 2, 3, 5, 4
- Serial troponin assays 3, 4, 6
- Risk stratification scores, such as TIMI and HEART scores 3, 4, 6
- Imaging modalities, such as coronary computed tomography angiography and transthoracic echocardiography 5, 4, 6
Management of Chest Pain
The management of chest pain involves: