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

Tissue damage
Inflamation
Stronge stimuli potentially damage

Modulator

P substance
chatecholamine

Opioid
serotonin

Modulation

Transmission

Cerebral cortex
Perception

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 fastconducting 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 Ribs
o intercostal muscles
o pleura
o esophagus

o
o
o
o
o

Heart
Lung
Aorta
Diaphragm
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.
2.
3.
4.

rapid stretching of the capsule of such solid visceral organs (pericard)

abrupt anoxia of cardiac muscles
inflammatory processes
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)