Basic Arrhythmias

Interpretation

Cardiac
Electrophysiology

Natalie Bermudez, RN, BSN, MS

Clinical Educator for Telemetry
Microscopic Anatomy of Heart Muscle

Figure 18.11
 Cardiac Muscle Cells:
§ Myocardial Autorhythmic Cells
§ Membrane potential “never
rests” pacemaker potential.
§ Myocardial Contractile Cells
§ Have a different looking action
potential due to calcium
channels.
§ General cardiac cell stuff:
§ Intercalated discs
§ Allow branching of the
myocardium
§ Gap Junctions (instead of
synapses)
§ Fast Cell to cell signals
§ Many mitochondria
§ Large T tubes
: Cardiac muscle
Coordinating the Pump: Electrical Signal Flow

Figure 14-18: Electrical conduction in myocardial cells

Myocardial Cardiac Cell Types
P Cells
• Pacemaker cells
– Responsible for generation of action
potentials
– electrical activity

Cardiomyocytes
• Myocardial Cells
– Contractile cells that generate force
– Mechanical activity
 Cardiac Cell Activity
Electrical activity ALWAYS
precedes mechanical activity

Electrical activity can occur

without a mechanical response
(i.e. pulse).

This is known as pulseless

electrical activity (PEA).
 Primary Characteristics of
Cardiac Cells
Automaticity

Excitability

Conductivity

Contractility
 Electrolytes and Cardiac Cells
• Electrolyte solution surrounds cardiac cells
• K+ primary intracellular ion
• Na+ primary extracellular ion
• Ready State: Inside of the cell
more negative
• Cell stimulated; membrane permeability
changes
 Electrical Activity at the Cellular Level

Polarization

Depolarization

Repolarization
 POLARIZATION

Electrical charges are balanced and

ready for discharge.
 DEPOLARIZATION
The discharge of energy that accompanies
the transfer of electrical charges across
the membrane.

The process of electrical discharge and flow

of electrical activity.

An electrical event that can be recorded on

an EKG or rhythm strip.
 REPOLARIZATION

The return of electrical charges across

the cell membrane.
 Cardiac Action Potential
• As cardiac cells reverse polarity, the electrical
impulse generated during that event creates an
energy stimulus that travels across the cell
membrane
• High-speed, self-producing current (heart only)
 Slow-Response Cells
• SA node & AV node
• Spontaneously depolarize slowly
• Shorter, non-prominent plateau phase with
slower repolarization period
 Fast-Response Cells
• Purkinje cells and working myocardial
cells
• Rapid depolarization
• Then, a period of sustained depolarization
– plateau phase
 Phases of Action Potential

Phase 0
• Cellular depolarization is initiated as + ions enter the
cell (Na+ and Ca++)
• Working cells rapidly depolarize as Na+ enters the
cells through Na+ fast channels (fast response)
• SA/AV node depolarize as Ca++ enters the cell
through Ca++ slow channels (slow-response)
 Phases of Action Potential

Phase 1
• Small, early, rapid repolarization as K+ exits the
intracellular space
Phase 2
• The plateau phase as Ca++ ions enter the intracellular
space
Phases of Action Potential

Phase 3
• Completion of repolarization and return of cell to
resting state
Phase 4
• Resting phase before the next depolarization (Na+
out, K+ in)
Action potential of a cardiac contractile cell
Action potentials of Autorhythmic Cells:
Pacemaker potential

Depolarization due to calcium NOT sodium!

Action potentials in cardiac autorhythmic cells
Autorhythmic Cells: Initiation of Signals
§ Pacemaker membrane potential
§ I-f channels Na+ influx
§ Ca++ channels – influx, to AP
§ Slow K+ open – repolarization

Funny current (or funny channel, or If, or IKf, or pacemaker

current) refers to a specific current in the heart. The funny current
is highly expressed in spontaneously active cardiac regions, such
as the sinoatrial node (SAN, the natural pacemaker region), the
atrio-ventricular node (AVN) and the Purkinje fibres of conduction
tissue.
Pacemaker and Action Potentials of the Heart

Figure 18.13
Sympathetic and Parasympathetic
§ Sympathetic – speeds heart rate by ­ Ca++ & I-f
channel flow
§ Parasympathetic – slows rate by ­ K+ efflux & ¯
Ca++ influx

Figure 14-17: Modulation of heart rate by the nervous system

Coordinating the Pump: Electrical Signal Flow

Figure 14-19a: Electrical

conduction in the heart
Cardiac Muscle Contraction

§ Heart muscle:
§ Is stimulated by nerves and is self-excitable
(automaticity)
§ Contracts as a unit
§ Has a long (250 ms) absolute refractory period

§ Cardiac muscle contraction is similar to skeletal

muscle contraction
Heart Physiology: Intrinsic Conduction System

§ Autorhythmic cells:
§ Initiate action potentials
§ Have unstable resting potentials called pacemaker
potentials
§ Use calcium influx (rather than sodium) for rising
phase of the action potential
The Heart: Conduction System

• Intrinsic conduction system

(nodal system)
• Heart muscle cells contract, without nerve
impulses, in a regular, continuous way
The Heart: Conduction System

• Special tissue sets the pace

• Sinoatrial node (right
atrium)
• Pacemaker
• Atrioventricular node
(junction of r&l atria
and ventricles)
• Atrioventricular bundle
(Bundle of His)
• Bundle branches (right
and left)
• Purkinje fibers
 Refractory Period
Absolute: The brief period during repolarization
when the cell CAN’T respond to any stimulus,
no matter how strong.

*Relative: The brief period during repolarization

when excitability is depressed. If stimulated, the
cell may respond, but a stronger than usual
stimulus is required.

Supernormal: The cells will respond to a weaker

than normal stimulus (this period occurs just
before the cells have completely repolarized)
Nervous System Stimulation
Sympathetic Nervous System: causes
an increase in heart rate, increase in AV
conduction , and increase in ventricular
contractility

The increase is caused a release of

norepinephrine
(catecholamine/neurotransmitter)
Nervous System Stimulation
Parasympathetic Nervous System: (from the
vagus nerve) causes a slowing of the heart
rate, a decrease in AV conduction, and a
slight decrease in ventricular contractility

The decrease is caused a release of

acetylcholine
(catecholamine/neurotransmitter)
 Pacemaker
Pacemaker – the SA node is the natural/normal
pacemaker of the heart.

Latent Pacemaker Cells – Cells in the electrical

conduction system located below the SA node with
the property of automaticity

These cells hold the property of automaticity in

reserve in case the SA node fails to function
properly or electrical impulses fail to be conducted.

a.k.a. – Subsidiary pacemaker cells

Heart Physiology: Sequence of Excitation

Figure 18.14a
The Electrical Conduction Pathway
 SA Node
• ie. Sinoatrial Node or Sinus Node
• Posesses the highest level of automaticity
• SA Node is the primary pacemaker of the
heart
• If it fails to fire or slows down less than its
inherent firing rate (60 – 100), another
pacemaker that is lower in the conduction
system will take over
 AV Node (The Gatekeeper)
Three main functions:
• Slows conduction to allow time for the
atria to contract & empty its contents
(atrial kick) before the ventricles contract
• Secondary pacemaker (40 – 59 bpm)
• Blocks some of the impulses from being
conducted to the ventricles when atrial
rate is rapid
 AV Node (The Gatekeeper)
Three Regions:

• Atrial-Nodal (upper region)

Pacemaker cells

• Nodal (middle region)

No pacemaker cells (area responsible
for delay)

• Nodal-His (lower region)

Pacemaker cells
 Ventricular Conduction
Impulses moves rapidly through the
ventricles:
• Bundle of His
• Left & Right Bundle branches (LBB divides
into the anterior fascicle and posterior
fascicle)
• Purkinje fibers

Tertiary pacemaker (20 – 39)

Heart Excitation Related to ECG

Figure 18.17
Extrinsic Innervation of the Heart

§ Heart is stimulated
by the sympathetic
cardioacceleratory
center
§ Heart is inhibited by
the parasympathetic
cardioinhibitory
center

Figure 18.15
Electrocardiography
§ Electrical activity is recorded by electrocardiogram
(ECG)
§ P wave corresponds to depolarization of SA node
§ QRS complex corresponds to ventricular
depolarization
§ T wave corresponds to ventricular repolarization
§ Atrial repolarization record is masked by the larger
QRS complex
Electrocardiograms (EKG/ECG)

• Three formations
– P wave: impulse across atria
– QRS complex: spread of impulse down septum,
around ventricles in Purkinje fibers
– T wave: end of electrical activity in ventricles
The electrocardiogram
Cardiac muscle polarization & ECG

SA node
AV node
Electrocardiography

Figure 18.16