THE NORMAL HEART
Biochemistry and physiology
of cardiac muscle
Adam Nabeebaccus
Ajay M Shah
Abstract
The heart is composed of muscle cells (cardiomyocytes) that account for
most of the heart mass and generate its pumping force. Other cell types
(fibroblasts, vascular endothelial cells, vascular smooth muscle cells, im-
mune cells) and the extracellular matrix also play key roles in cardiac func-
tion, both in health and in disease. Excitationecontraction coupling links
the electrical activation of cardiomyocytes to cellular contraction. Calcium
is a key second messenger in this process; its entry into the cell triggers
further calcium release from the sarcoplasmic reticulum, which then acti-
vates the contractile machinery. Subsequent reduction in calcium concen-
tration brings about cardiac relaxation, which is necessary for the heart to
re-fill. Calcium also regulates other critical processes in the heart
including transcription of genes and the matching of energy supply
from the mitochondria with cellular demand. In health, the contractile
function of the heart is regulated by several factors, including its loading
conditions, autonomic influences and many locally produced autocrine/
paracrine agents. These factors alter contractile strength through two
main mechanisms, namely the modulation of the calcium transient within
cardiomyocytes and/or changes in myofilament sensitivity to calcium.
Keywords Calcium; cardiomyocyte; contractile function; excitation
econtraction coupling; fibroblasts; myofilament
The synchronous contraction of cardiomyocytes during ventricu-
lar systole generates the power required to pump blood out of the
heart. Conversely, active myocyte relaxation and passive me-
chanical properties of the ventricles (the latter largely dependent
on the extracellular matrix) determine filling of the heart during
diastole. Several interacting regulatory processes operate to ensure
that cardiac performance is finely tuned to match changing circu-
latory requirements. In this article, we provide an overview of the
mechanisms that regulate cardiac contractility, dysfunction of
which is implicated in disease states such as heart failure.
Structure of the myocardium
The heart is composed of cardiomyocytes, fibroblasts, endocar-
dial and endothelial cells, immune cells, coronary vessels, and
the extracellular matrix.
Adam Nabeebaccus MB ChB MRCP is an MRC Clinical Research Training
Fellow at Kings College London, UK. His research interest is the
mechanisms of cardiac remodelling in response to chronic cardiac
stress. Competing interests: none.
Ajay M Shah FRCP FMedSci is BHF Professor of Cardiology and Director of
the Kings College London BHF Centre of Excellence, London, UK. His
research interest is the pathophysiology of cardiac remodelling.
Competing interests: none.
MEDICINE 42:8
Whats new?
C Cross-talk between different cell types within the heart (car-
diomyocytes, endothelial cells, fibroblasts) is important both
for normal physiological function and in the diseased heart
C Calcium regulates numerous intracellular processes within
myocytes, including excitationecontraction coupling, excitation
etranscription coupling and mitochondrial function. This is
achieved through spatial and temporal compartmentation of
the calcium signal in cellular microdomains
C Autocrine/paracrine factors and downstream signalling path-
ways (e.g. those regulated by eNOS and nNOS) are important
modulators of cardiac function both in health and disease
C Immune cells reside in the normal myocardium and can also be
attracted after cardiac injury. They interact with cardiomyocytes
and fibroblasts to initiate an innate immune response that can
be detrimental or reparative depending upon the context
C Epigenetic regulation and regulation by microRNAs are impor-
tant modulators of cardiac structure and function in health and
disease
Cardiomyocytes account for most of the cardiac mass and
volume but only approximately 30% of cardiac cell numbers.
They are connected to each other via specialized gap junctions,
which provide electrical coupling and allow an action potential to
spread between adjacent cardiomyocytes by the intercellular
movement of ions. This is vital for synchronized contraction of
myocytes. Gap junction channels are formed from a family of
proteins known as the connexins.
The sarcolemmal membrane of cardiomyocytes has in-
vaginations that form an extensive T-tubule network, regions of
which lie in close apposition with the sarcoplasmic reticulum
(SR). The sarcoplasmic reticulum is the major intracellular store
of calcium and a central regulator of cardiac contractility. The
fundamental contractile unit, the sarcomere, is formed from
contractile myofibrils, which comprise interdigitating thin fila-
ments (actin and associated regulatory proteins, tropomyosin,
and troponins C, I and T) and thick filaments (myosin). The
sarcomere also contains numerous non-contractile proteins (e.g.
titin, myomesin, telethonin) that have important structural and
signalling functions. Interspersed between the myofibrils are
numerous mitochondria, which generate the energy (in the form
of ATP) to fuel contraction.
Fibroblasts are the most numerous cells in the heart. They are
responsible for the continual production and turnover of the
extracellular matrix of the heart. In response to injury, such as
myocardial infarction, fibroblast numbers are increased and un-
dergo a phenotypic change, to so-called myofibroblasts, which
play a crucial role in organ repair and healing by fibrosis.1 In
experimental models of cardiac injury, some of these myofibro-
blasts may be recruited from circulating bone marrow-derived
cells or from local endothelial cells that have undergone a
phenotypic change known as endothelialemesenchymal
transition.2
The extracellular matrix (ECM) is a complex array of mole-
cules that provides structural support for the cellular components
413 2014 Elsevier Ltd. All rights reserved.
 THE NORMAL HEART
of the heart. The ECM also allows appropriate transmission of the
mechanical forces generated by cardiomyocytes. The major
components of the ECM are types I and III collagen. The ECM
also contains various protease enzymes, which allow degrada-
tion of matrix components. Important among these are the ma-
trix metalloproteinases (MMPs), of which there are over 20
known subtypes.
The main coronary arteries, which provide the heart with its
blood supply, sit on the epicardial surface of the heart. They
divide into smaller blood vessels that penetrate the myocardium.
At capillary level, there is a close apposition between endothelial
cells and cardiomyocytes. These endothelial cells not only pro-
vide the lining of blood vessels but also modulate cardiac func-
tion through the release of diffusible factors (described later).
Immune cells also reside in the healthy myocardium and
interact with cardiomyocytes, fibroblasts and the ECM to help
maintain normal myocardial structure and function. In the
injured myocardium (e.g. after myocardial infarction or in
chronic heart failure), a change in immune cell number and sub-
type makes an important contribution to the overall myocardial
remodelling process.3 Damage-associated molecular patterns
(DAMPS), comprising components of injured cells and tissues,
are involved in stimulating immune responses. The effect of
immune activation ranges from damaging inflammatory re-
sponses to tissue reparative processes whose overall balance
dictates the acute and chronic response to cardiac injury.3
Excitationecontraction coupling and contractile function
Electrical excitation of the cardiomyocyte initiates a dramatic
transient rise in intracellular calcium concentration (the so-called
calcium transient). The events that couple sarcolemmal depo-
larization to elevation of calcium concentration and initiation of
contraction are known as excitationecontraction coupling
(Figure 1). During each heartbeat, the depolarization wave
spreads across the sarcolemma and T-tubule system, and initi-
ates calcium influx through voltage-gated L-type calcium chan-
nels. This calcium influx or calcium current (ICa) initiates further
calcium release from the SR (calcium-induced calcium release)
via the ryanodine receptor. The elementary unit of SR calcium
release, the calcium spark, represents calcium released locally
from the opening of a few calcium-release channels. According to
the local control theory of excitationecontraction coupling, the
cell calcium transient induced by an action potential represents
the spatial and temporal summation of individual calcium
sparks.
The contractile machinery is switched on by binding of cal-
cium to troponin-C on the thin filament, which enables pro-
jections (S1 heads) on the myosin molecules to interact with
actin filaments, forming cross-bridges. This energy-requiring
process involves ATP hydrolysis by myosin ATPase. Repetitive
cross-bridge cycles of attachment and detachment continue as
long as the cytosolic calcium concentration is high. The power
stroke generated by the cross-bridge cycle is responsible for force
generation or muscle shortening. Cross-bridge interactions show
cooperativity; in other words, force-generating cross-bridges
promote further binding of more cross-bridges, which effectively
amplifies the calcium signal.
MEDICINE 42:8
Muscle relaxation is governed by lowering of the cyto-
plasmic calcium concentration, consequent dissociation of cal-
cium from troponin-C, and switching off of the actinemyosin
interaction. This involves active transport of calcium back into
the SR (via SR Ca2-ATPase) and extrusion across the sarco-
lemma, by both the NaeCa2 exchanger and (less impor-
tantly) the sarcolemmal Ca2-ATPase. Mitochondria can also
accumulate calcium, particularly when cytosolic concentrations
become excessively high (e.g. during severe ischaemia). In
addition to the reduction in cytosolic Ca2, recoil of elastic el-
ements within the myocyte (notably within titin molecules in
the sarcomere) may also be involved in the process of
relaxation.
The events that comprise excitationecontraction coupling
influence the size and kinetics of the calcium transient.4 An
abnormally low calcium transient may lead to depressed
contractility. Reduction in SR Ca2-ATPase activity and abnor-
malities of SR calcium release (e.g. calcium leak) occur in heart
failure and are generally accompanied by diastolic calcium
overload; this may contribute to delayed relaxation and diastolic
dysfunction, triggering of ventricular arrhythmias, and chronic
changes in cell structure (e.g. altered gene expression) as a result
of activation of downstream calcium-dependent signalling path-
ways.4 Up-regulation of NaeCa2 exchanger activity may, to
some extent, compensate for reduced SR Ca2-ATPase activity.
Independent of excitationecontraction coupling, changes in
myofilament properties (e.g. their responsiveness to calcium) are
also implicated in heart failure, ischaemiaereperfusion injury
and hypertrophic cardiomyopathy.5
Calcium concentrations within the cardiomyocyte also influ-
ence other cellular processes. They have been found to be
involved in the control of gene transcription (so-called excitation
etranscription coupling) and may in part mediate processes such
as cardiac hypertrophy. The binding of calcium to calmodulin
leads to activation of certain protein kinases (e.g. calmodulin
kinase) or phosphatases (e.g. calcineurin), which then modulate
signal transduction pathways and/or transcription factors to alter
the expression of specific genes.6
Calcium is involved in matching mitochondrial energy pro-
duction (by oxidative phosphorylation) to cardiac work.
Various sites within mitochondria, including key de-
hydrogenases (such as pyruvate dehydrogenase and alpha-
ketoglutarate dehydrogenase) and also the F1F0 ATPase, are
susceptible to changes in activity determined by local calcium
concentration. An abnormality in calcium handling therefore
affects not only excitationecontraction coupling but also mito-
chondrial metabolism, leading to a cellular energetic deficit and
oxidative stress.7 The consequent ATP deficit and redox
imbalance may further impair excitationecontraction coupling
and contractile function.
The multiple described actions of calcium within the car-
diomyocyte are feasible because of distinct local calcium con-
centrations within the cell, in so-called microdomains. For
example, excitationecontraction coupling (involving sarco-
lemmal ICa and SR ryanodine receptors in close proximity) is
likely to involve a local free calcium transient signal that is
spatially distinct from that seen in perinuclear pathways identi-
fied in excitationetranscription coupling.
414 2014 Elsevier Ltd. All rights reserved.

Excitationcontraction coupling in cardiac myocytes
Na+Ca2+ exchanger
3Na+
Sarcolemma
Ca2+
The wave of depolarization
spreading along the sarcolemma
Sarcoplasmic
and T-tubule system initiates reticulum
calcium entry via L-type calcium
channels (the calcium current),
which stimulates further calcium
release from the sarcoplasmic Sarcoplasmic
reticulum. The resulting rise in
intracellular calcium Ca2+ Ca2+-ATPase
concentration activates the
contractile machinery (actin and
myosin filaments). Following
contraction, the cytoplasmic
calcium concentration is
reduced again by transport back
into the sarcoplasmic reticulum filaments
(Ca2+-ATPase) and across the
sarcolemma (Na+Ca2+ exchange
and sarcolemmal Ca2+-ATPase),
thus allowing relaxation.
Figure 1
Contractile reserve and regulation
Considerable contractile reserve (Figure 2) is normally available
to meet variations in circulatory demand, e.g. during exercise. At
a cellular level, the recruitment of this contractile reserve in-
volves changes in the cytosolic calcium transient and/or
myofilament responsiveness to calcium, and is regulated by
several important pathways as outlined below. There is usually
significant impairment of these pathways in heart failure, which
is a major reason for the exercise intolerance characteristic of this
condition.
The FrankeStarling response describes an increase in con-
tractile force that occurs with increasing myocyte length or
stretch (the latter brought about by increased ventricular dia-
stolic volume). The main underlying mechanism is an increase in
myofilament responsiveness to calcium, but length-dependent
release of autocrine/paracrine factors may also be involved.
The FrankeStarling response is thought to be preserved at a
cellular level in human heart failure, but in a heart that is dilated
and stiff it may be functionally impaired by limitation in the
ability to stretch myocytes.
An increase in heart rate enhances contractile force primarily
by increasing sarcolemmal calcium influx per unit time, with
consequent increased calcium loading of the SR. This normal
positive forceefrequency relationship is greatly blunted or even
becomes negative in heart failure.
Autonomic control is centrally involved in contractile regu-
lation. Sympathetic activation, involving catecholamine release,
MEDICINE 42:8
THE NORMAL HEART
L-type
Ca2+ Ca2+ channel
Ca2+
Sarcolemmal
Ca2+-ATPase
T-tubule
Mitochondrion
Ca2+ Ca2+
Sarcoplasmic
reticulum reticulum
Ca2+-release (Ca2+)
channel
Z line
Myosin Actin
filaments
One sarcomere
has both positive inotropic and chronotropic effects via b-adre-
noceptors. These actions are antagonized by parasympathetic
release of acetylcholine. The inotropic effect of b-stimulation
results from an increase in the intracellular calcium transient
caused by increases in ICa and SR calcium release. b-Stimulation
also accelerates relaxation (lusitropic action) by stimulating SR
calcium uptake, promoting faster dissociation of calcium from
the myofilaments, and accelerating cross-bridge cycling. The
predominant mechanism for enhanced SR calcium re-uptake here
is phosphorylation of phospholamban, thereby relieving tonic
inhibition on the SR ATPase by this protein. Reduced respon-
siveness to b-adrenergic stimulation is a fundamental feature of
human heart failure.
Autocrine/paracrine regulation e the endothelial cells within
the coronary microvasculature, fibroblasts and cardiomyocytes
themselves all release bioactive factors that may regulate cardiac
contraction as well as having chronic effects on cardiac structure.
The physiological release of such factors is likely to involve local
signals such as mechanical forces, oxygen tension and local
autacoids.8
In the physiological setting, nitric oxide may have direct ac-
tions on cardiomyocytes, independent of its vasodilator effects.9
These include an acceleration of myocyte relaxation and reduc-
tion in diastolic tone, resulting from a reduction in myofilament
calcium responsiveness; modulation of excitationecontraction
coupling; and a damping down of responses to b-adrenergic
stimulation. Both endothelial and neuronal isoforms of nitric
oxide synthase (i.e. eNOS and nNOS) are expressed in the heart
415 2014 Elsevier Ltd. All rights reserved.
 THE NORMAL HEART

Contractile reserve

Calcium Activation
Nitric oxide
Acetylcholine current

+ Ca2+
Sarcoplasmic Ca2+ Ca2+
reticulum Ca2+ transient
-stimulation +
release
Heart rate
Ca2+ Negative
inotropic effect
Angiotensin II +
Myofilament activation +
Endothelin-1
Positive
Length
inotropic effect

Relaxation

+ Sarcoplasmic
reticulum
-Stimulation Decreased
+ Ca2+ uptake
cytoplasmic
Ca2+ concentration
Sarcolemmal
-Stimulation Ca2+ extrusion
Positive
Nitric oxide + + lusitropic effect
Myofilament
Ca2+ dissociation
Angiotensin II
Negative
Endothelin-1
lusitropic effect
Length

These are the major pathways by which muscle length, heart rate, autonomic control (-adrenergic stimulation) and paracrine factors (nitric
oxide, endothelin-1 and angiotensin II) produce changes in:
level of activation and contractile strength (inotropic effects, top)
rate of relaxation (lusitropic effects, bottom).
Blue arrows indicate an increase and red arrows a decrease in the components of excitationcontraction coupling. Effects of nitric oxide and
acetylcholine on the calcium current are significant only following prior -adrenergic stimulation.

Figure 2

and exert isoform-specific actions.9 Abnormal nitric oxide
bioactivity (excessively low or high) contributes to contractile
dysfunction in cardiac hypertrophy, heart failure and
myocarditis.
Other local factors such as endothelin-1, angiotensin II and
reactive oxygen species (ROS) also modulate contractile proper-
ties and remodelling, particularly in the diseased heart. ROS
release has been shown to modulate the physiological effects of
increased stretch to enhance contraction.10 Endothelin-1 has
potent hypertrophic effects and may also stimulate release of
angiotensin II, which has similar actions. Increased angiotensin II
production through increased local angiotensin-converting
enzyme activity is a cardinal feature of hypertrophy and heart
failure, contributing to inappropriate hypertrophy, fibrosis and
slowed ventricular relaxation. The increased generation of ROS,
such as superoxide and hydrogen peroxide, is involved in many
of the effects of angiotensin II within the heart. ROS may also
induce abnormal sarcoplasmic reticulum calcium release or
activate detrimental signalling pathways that contribute to the
development of heart failure.11 These pathways may provide
novel therapeutic targets in heart failure.
Epigenetic regulation is increasingly recognized to have a role
in cardiac hypertrophy, fibrosis and contractile regulation.12 The
term refers to modulation of gene expression through mecha-
nisms such as DNA methylation, ATP-dependent chromatin
remodelling and other histone modifications (acetylation and
methylation), rather than transcription factors. Non-coding RNAs
including microRNAs (miRNAs) play important regulatory roles

MEDICINE 42:8 416 2014 Elsevier Ltd. All rights reserved.

 THE NORMAL HEART
at a post-transcriptional level by binding to messenger RNAs
(mRNAs) to silence their translation or promote degradation.
Individual miRNAs generally target multiple mRNAs encoding
proteins in the same signalling pathway, and therefore may have
profound effects on cellular function. To date, epigenetic and
miRNA regulatory mechanisms that alter contractile function
have been found to act principally through their effects on cal-
cium- and sodium-handling proteins and contractile proteins.
Targeting individual miRNAs could be a powerful therapeutic
approach because of the potential to influence entire signalling
pathways. A oxide signalling. Cardiovasc Res 2007; 75: 315e26.
REFERENCES
1 Weber KT, Sun Y, Bhattacharya SK, Ahokas RA, Gerling IC. Myofibro-
blast-mediated mechanisms of pathological remodelling of the heart.
Nat Rev Cardiol 2013; 10: 15e26.
2 Zeisberg EM, Tarnavski O, Zeisberg M, et al. Endothelial-to-mesen-
chymal transition contributes to cardiac fibrosis. Nat Med 2007; 13:
952e61.
3 Nahrendorf M, Swirski FK. Monocyte and macrophage heterogeneity
in the heart. Circ Res 2013; 112: 1624e33.
4 Luo M, Anderson ME. Mechanisms of altered Ca2 handling in heart
failure. Circ Res 2013; 113: 690e708.
5 Hamdani N, Kooij V, van Dijk S, et al. Sarcomeric dysfunction in heart
failure. Cardiovasc Res 2008; 77: 649e58.
MEDICINE 42:8
6 Goonasekera SA, Molkentin JD. Unraveling the secrets of a double
life: contractile versus signaling Ca2 in a cardiac myocyte. J Mol Cell
Cardiol 2012; 52: 317e22.
7 Kohlhaas M, Maack C. Interplay of defective excitationecontraction
coupling, energy starvation, and oxidative stress in heart failure.
Trends Cardiovasc Med 2011; 21: 69e73.
8 Brutsaert DL. Cardiac endothelial-myocardial signaling: its role in
cardiac growth, contractile performance, and rhythmicity. Physiol Rev
2003; 83: 59e115.
9 Seddon M, Shah AM, Casadei B. Cardiomyocytes as effectors of nitric
10 Prosser BL, Ward CW, Lederer WJ. X-ROS signaling: rapid mechano-
chemo transduction in heart. Science 2011; 333: 1440e5.
11 Burgoyne JR, Mongue-Din H, Eaton P, Shah AM. Redox signaling in
cardiac physiology and pathology. Circ Res 2012; 111: 1091e106.
12 Kumarswamy R, Thum T. Non-coding RNAs in cardiac remodeling and
heart failure. Circ Res 2013; 113: 676e89.
FURTHER READING
Bers DM. Excitationecontraction coupling and cardiac contractile force.
2nd edn. Springer, 2001. An excellent, detailed account of all aspects
of excitation-contraction coupling.
Katz AM. Physiology of the heart. 5th edn. Lippincott Williams and Wil-
kins, 2010.
Shah AM, Mann DL. In search of new therapeutic targets and strategies for
heart failure: recent advances in basic science. Lancet 2011; 378: 704e12.
417 2014 Elsevier Ltd. All rights reserved.