PHYSIOLOGY

SA Node
1. Automaticity AV Node
Purkinje Cells

AV node Slow conductance

Properties of cardiac tissue 2. Conduction
Purkinje cells Fast conductance

3. Contractility Myocytes
 Sinoatrial (SA) Node:
PROPERTIES OF CARDIAC TISSUE Normal pacemaker of the heart, because
it has the highest intrinsic rhythm
(~ 100/min)

Atrioventricular (AV) Node:

Automaticity Second highest intrinsic rhythm
(40 60/min)

Purkinje cells: (~ 35/min)

 Small diameter fibers

AV Node Specialized Low density of gap

in slow conductance junctions

Rate of depolarization
(phase 0) is slow
CONDUCTION
Big diameter fiber
(gap junctions)

Purkinje cells Specialized for fast

Lots of gap junctions
conduction

Depolarization is fast
They like nerve but theyr not nerve
Thats why theyr specialized for FAST CONDUCTION
Myocytes
 Atrial muscle
Highest intrinsic CONDUCTION PATHWAY
Rate (100-120/min)

SA Node
SA Node AV Node

Internodal fiber
Second
highest AV Node Slowest intrinsic rate
Intrinsic rate Fast conduction
40 60/min
(Delay)
Purkinje Fibers
Slowest
conduction

Ventricular muscle
Purkinje Cells (Purkinje system)
 (Non Nodal)
+ conductance
( + )
Ungated (leak) channels

(1 )

Deporalization closes
opens as membrane starts
to repolarize +
+ +
+ +
Phase 0 Phases of Action potential
0: Upstroke (+ )
Upstroke of action potential 1: Slight repolarization ( + )
High conductance + (Fast 2: Plateau (L-type 2+ and )
+ Channels) 3: Repolarization
4: Resting ( )
Conduction velocity directly related to
slope
Activation of -1 (Gs-cAMP) increased
conduction velocity (More rapid rate of
depolarization)
Complex QRS +
Class I Anti-arrhythmics + +
1A (Open State) Quinidine, Procainamide
1B (Inactivade) Lidocaine, Mexiletine, + + +

Tocainide + +
1C Flecainide
 + (out) 2+ (in) Phase 1
Partial repolarization mediated by +
+ Conductance goes down
+ Channels inactivated
Phase 2
Depolarization opens L type +
channels (Voltage-gated)
+ - induced + release from
Sarcoplasmic Reticulum
This cause prolonged action potential thus
no tetany
Current opens by deporalization
SR segment of EKG
Very long absolute refractory period
Absolute Refractory Periodo
Phase 3 + (out)
REPOLARIZATION
remain open
channels reopen and aid in
repolarization
L type + begin to close
T wave of EKG
Class III Anti-arrhythmics Blocks +
channels
Amiodarone
Sotalol
Class IA have effects also
1A (Open State)
Quinidine
Procainamide
 + (out)

Phase 4
Fast + closed
+ channels closed
(delayed rectifier closed)
Inward rectifier remain
open
Class I Anti-
arrhythmics
Blocks Fast
+ Channels
 Fast Class I Anti-
Phase 0 +
Channels arrhythmics

Voltage gated
Phase 1
+

ACTION L type 2+
Non-Nodal 5 Phases Phase 2
POTENTIAL Current

Class III Anti-

Phase 3
arrhythmics

Phase 4
 PATHOLOGY INTEGRATION
Fast + Channels slow to
inactivate
This Fast + Channels
current will delays
repolarization
Delay repolarization causing
long QT segment
Basic of congenital long QT
Na+ conductance Torsades de points
 Nodal cell has 3 phases (4, 0 and 3)
Phase 4 (Pacemaker Resting
membrane)
Inward + channels (T type)
Inward + (funny current )
Hyperpolarization activated cyclic
nucleotide gated (HCN) channel
600 msec cAMP modulated the
+ current
300 450 600 750
Class III anti arrhythmics
 Phase 0
Upstroke of action potential
Phase 0 + (L & T type) current in
Phase 3 nodal cells

Phase 3
Repolarization
Mediated by voltaje gated +
channels ( )
+ efflux
Sympathetics
Norepinephrine (NE)
Epinephrine (EPI)
1 receptor; GscAMP
Depolarize faster
SN Node will increase heart rate
AV Node will increased Conduction
velocity
SN Node
Increased Heart Rate
Effects on heart
AV node
Increased conduction velocity
Class II Anti-arrhythmics ( Blockers)
Propanolol
Decreases automaticity
Esmolol
Clase IV Anti arrhythmics (+ channels
blockers)
Verapamil
Diltiazem Decreases automaticity
Acetylcholina (release from
post ganglionar fiber)
receptor; Gi G0;
OPENS K+ channels
INHIBIT cAMP
If cAMP goes down the
funny current
(+ channels BLOCKED)
 Hyperpolarizes
Reducing the funny current
Gets longer to get to threshold
Hyperpolarizes; reduce slope of
pacemaker potential
Functional effect
Negative chronotropy (SA node)
Decreased HR
-
Negative dromotropy (AV node) Blocks
OPENS
Decreased conduction velocity +
Because OPENS K+ channels so
the action potential at rest gets Pharm Integration
more negative and takes more time
to depolarizes (to get to threshold) Adenosine has a like
effect
 Nodal

3 Phases

Phase 0 Phase3 Phase 4

Inward + channels (T type)

+ (L & T type) Voltaje gated + channels ( ) Inward + (funny current )
+ current
 Inward + (funny
Norepinephrine (NE) 1 receptors current ; HCN)
Catecholamines
Epinephrine cAMP; stimulates
OPENS +
Channels
Class II Beta - Blockers
Nodal cell

Drugs
Class IV + channles
Blockers

Acetylcholine receptor
Parasympathetics Gs
Inhibit cAMP
Adenosine likeeffect
 Ventricular Action
Potential Versus ECG

Ventricular
depolarization

Atrial Ventricular
depolarization Repolarization
 P wave Atrial depolarization
Complex QRS First upward
deflection after P wave
Ventricular depolarization
Phase 0 of the ventricular
action potential
T wave Ventricular
reporalization
Phase 3 of EKG
PR interval: start of the P wave to
start of the QRS complex
Function of AV node
Sympathetics conduction of AV
node
PR Interval gets smaller
Parasympathetics conduction of
AV node
PR Interval gets bigger
 ST segment start of the QRS complex to
the end of the T wave
Ischemia injury (elevation or
depression)
Related to Phase 2
J point
It determines if the ST segment changed
Height of traces directly related to
1. Mass
2. Rate of change in membrane
3. Orientation of lead
 Y-axis (volts): one big box = 0.5
mV - measures amplitude
Because there are 7 big boxes, the
total height is 3.5 mV.
X-axis (time): one big box = 0.2 sec
(200 msec)
Because there are 5 subdivisions
within each big box, each small box is
0.04 sec (40 msec),
5 big boxes equal one second.
Step 1 Rhythm and Rate
Steady rhythm
R waves same distance apart
Heart Rate
R R Interval
Shorter RR Interval HR
Wider RR Interval HR
Number of big box
1 = 300 beats/min
2 = 150
3 = 100
4 = 75
5 = 60
6 = 50 Tachycardia: HR 100 bmp Bradycardia: HR 60 bmp
Step 2: Waves
Pattern: PQRST
Quantitate PR Interval
Start at P wave and count the
boxes to the Q wave
This normal range translates
into 3-5 small boxes (Normal)
 Look up: NEGATIVE

Step 4: Estimate the mean

electrical axis (MEA) aVR aVL
Net direction of ventricular
Right arm
depolarization Left arm
POSITIVE
NEGATIVE
Normal axis: 30 +110
Qualitatively determine if QRS is:
Net positive
Net Negative
No net deflection (Isoelectric)
Look down: POSITIVE
 NET DEFLECTION (Voltage)
QRS: More going up QRS More going down and QRS same up and down
and less going down less going up NO NET DEFLECTION
NET POSITIVE NET NEGATIVE
 Left axis
MEAN ELECTRICAL AXIS deviation

Causes LAD
Normal Enlargment of left ventricle (hypertrophy
lead +I or dilataion
lead +aVF Left ventricular conduction defects, Right axis
except posterior Bundel Branch
normal axis Acute right side MI unless right ventricle deviation
Left axis deviation dilates
lead +I
Causes RAD
lead aVF
Enlargment of right ventricle
Right axis deviation (hypertrophy or dilataion
Right ventricular conduction defects,
lead I except posterior Bundel Branch
Acute left side MI unless left ventricle
lead +aVF dilates
 300
150
100
75
60
55
1. Steady rhythm 3. Pattern: P QRS T

2. HR: 60 (Normal) 4. PR Interval:

8 small boxes: 8 X 0.04 = 0.32
Normal: 3 5 small boxes
First Degree heart Block
 Every QRS is preceded by a
P wave, but no every P wave
is followed by a QRS

1. Unsteady rhythm 3. Pattern: P QRS T

2. HR: < 60 (Bradycardia)

4. PR Interval:
> 5 small boxes (progressive prolongation PR
Second Degree heart Block Interval until ventricular beat is missed)
Wencheback (Mobitz type I) Normal: 3 5 small boxes
1. Unsteady rhythm 3. Pattern: P QRS T
Mobizt II could have a steady rhythm

2. HR: 60 (Bradycardia) 4. PR Interval:

PR > 0.2 sec consistent pattern
Normal: 3 5 small boxes

Second Degree heart Block (MOBIZT II)

 Complete dissociation between
P waves and QRS

100
300
150

75
60
55
1. Steady rhythm 3. Pattern: P QRS T
NO PATTERN
2. HR: < 60 (Bradycardia)
Very SLOW 4. PR Interval:
PR consistent pattern

Ventricular rate is
Third Degree heart Block TYPYCALLY slow
 Very fast atrial rate, but it is a
coordinated conduction

300
150
100
75
60
55
Saw Tooth
Pattern

3. Pattern: P QRS T
1. STEADY rhythm Saw Tooth Pattern

4. PR Interval:
2. HR: > 60 (Normal) PR NOT measureable
Very fast atrial rate (>280
beats/min)

Atrial Flutter
 Uncoordinated atrial
300
150 conduction
100
75
60
55

3. Pattern: P QRS T
1. UNSTEADY rhythm P wave NOT present

4. PR Interval:
2. HR: > 100 (Tachycardia) PR NOT measureable

Atrial Fibrillation
 Accesory pathway
atrial to ventricules
Bundle of Ken
300
150
100
75
60
55

3. Pattern: P QRS T
1. STEADY rhythm
DELTA wave present
(diagnostic for WPW)

2. HR: < 60 (Brachycardia) 4. PR Interval:

SHORT PR Interval

Wolf Parkinson White (WPW)

 CHANGES IN ST
SEGMENT
ELEVATION
Transmural infarction
Prinzmetal angina
Cause by Coronay vasospams
B-Blocker contraindicated
DEPRESSION
Subendocardial ischemia
Classic (stable) angina
Coronary arterial disease
Atherosclerosis
Blood clot
 HYPERKALEMIA HYPOKALEMIA
rate of REPOLARIZATION
rate of Repolarization U waves
Prolonged QT interval ()
Sharp-spiked T waves () Torsades of point
Pharmacology
Shortened QT interval () Class II Anti arrhythmics
Amiodarone
Sotalol
Class IA have inhibitory effects also
 HYPERCALCEMIA

Decreases the QT Interval Increases the QT interval

Shortened QT interval () Prolonged QT interval ()