Pathophyisiology

Chest Pain

© 2012 Pearson Education, Inc.

Capaian Pembelajaran

1. Mahasiswa mampu mengidentifikasi gejala khas dan

penyebab nyeri dada
2. Mahasiswa mampu menjelaskan etiologi nyeri dada
3. Mahasiswa mampu menjelaskan patofisiologi nyeri dada
Pain

• pain is an uncomfortable sensory and emotional experience with

both physiochemical and affective components which serves to
warn the individual of either physical or psychological damage.
• Pain is a complex unpleasant phenomenon composed of sensory
experiences that include time, space, intensity, emotion, cognition,
and motivation
• Pain is an unpleasant or emotional experience originating in real or
potential damaged tissue
Pain category

1. Somatogenic pain is pain with cause (usually known)

localised in the body tissue
a. nociceptive pain
b. neuropatic pain
2. Psychogenic pain is pain for which there is no known
physical cause but processing of sensitive information in
CNS is disturbed
Physiology of Pain

• Transduction: Nociceptors
• Transmission: A-delta, C fiber
• Perception
• Modulation
 Physiology of Pain
Transmission
Transduction
nociceptor Spinal cord Brain stem Thalamus
Modulation

Stimuli:  Chemical mediator release

Modulation Transmission
• Tissue damage Modulator
• Inflamation ↑
• Stronge stimuli potentially damage • P substance
• chatecholamine Cerebral cortex
Perception
↓
• Opioid
• serotonin
Physiology of Pain
Neuropathic pain

• It occurs as a result of injury to or dysfunction of the nervous

system itself, peripheral or central.
• common causes of neuropathic pain in chest:
• Shingles (Herpes zoster)
• Common symptoms: burning pain
• Radicular pain
• Multiple sclerosis
Neuropathic pain

• Hyperalgesia: increased the pain sensitivity to noxious stimuli

• Allodynia: phenomenon characterized by painful sensations
provoked by non-noxious stimuli, (e.g. touch), transmitted by fast-
conducting nerve fibres
• Mechanism: changes of the response characteristics of second - order
spinal neurons so that normally inactive or weak synaptic contact
mediating non-noxius stimuli acquire the capability to activate a neuron
that normally responds only to impulses signaling pain
Chest Pain

Definition
• Pain, pressure, tightness, or other discomfort originating in or
radiating to the chest
• constitutes an important indicator of potentially serious cardiac
or cardiovascular disorders.
• Pain: described as dull, heavy, or crushing, Sharp, stabbing,
or burning pain.
Origin
• Pain may originate from several different structures:
• within the chest:
o the skin o Heart
o Ribs o Lung
o intercostal muscles o Aorta
o pleura o Diaphragm
o esophagus o thoracic vertebrae

• Outside the chest: liver, pancreas, stomach

• The pain may be transmitted by intercostal, sympathetic, vagus,
and phrenic nerves.
Site of referred pain. A, Front. B, Back (from Phipps, Long & Woods, 1987)
Etiology

• Psychic origin
• Inflamation
• Ischemic-anoxic tissue
• Metabolic disturbance of tissue
• Tissue damage
• Trauma
• Inflamation
• Infection
• Ischemic-anoxic tissue
Pathophysiology of heart pain

• a part of visceral pain

• Types - angina pectoris, myocardial infarction, pericardial.
• Aferent: unmyelinated C – fibres
• Mechanism:
1. rapid stretching of the capsule of such solid visceral organs (pericard)
2. abrupt anoxia of cardiac muscles
3. inflammatory processes
4. necrosis of myocardium
Characteristic of angina

• it is dull, deep, not well defined, and differently described by the

patients
• Pain is radiated to some area
• it induces strong autonomic reflex phenomena (much more
pronounced than in pain of somatic origin)
1. diffuse sweating, vasomotor responses, changes of arterial
pressure and heart rate
2. an intense psychic alarm reaction -"angor animi" -
Etiology of anginal pain

• obstructive coronary disease

• myocardial ischemia
• myocardial infarction
Effect of heart pain

• Responses to acute pain

• increased heart
• increased respiratory rate
• elevated blood pressure
• pallor
• dilated pupils
• diaphoresis
• ↑ blood sugar
• ↓ gastric acid secretion
• ↓ gastric motility
• ↓ blood flow to the viscera, kidney and skin
• nausea occasionally occurs

• Psychological and behavioural response to acute pain

• fear
• general sense of unpleasantness or unease
• anxiety
Pathophysiology of oesophageal pain

• a part of visceral pain

• Aferent: unmyelinated C – fibres
• Mechanism:
1. direct action of chemical stimuli
2. inflammatory processes
3. abnormal distention and contraction of the hollow viscera muscle walls
Characteristic of Oesophageal pain

• it is dull, deep, not well defined, and differently described by the

patients
• There are many visceral sensation that are unpleasant but below
the level of pain:
• feeling of disagreeable fullness or acidity of the stomach
• undefined and unpleasant thoracic or abdominal sensation
• Sub sternal burn pain
Pathophysiology of muscle pain

• a part of somatic deep pain.

• it is common in rheumathology and sports medicine.
• Muscles are relatively insensitive to pain when elicited by needle
prick or knife cut, but overlying fascia is very sensitive to pain.
• Events, processes which may lead to muscular pain are:
• metabolic events:
• metabolic depletion (ATP ↓  muscular contracture)
• accumulation of unwanted metabolities (K+, bradykinin)