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Pacemaker Mechanisms in Cardiac Tissue: Dario Difrancesco
Pacemaker Mechanisms in Cardiac Tissue: Dario Difrancesco
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Annu. Rev. Physiol. 55:455-72 Quick links to online content
Copyright © 1993 by Annual Reviews Inc. All rights reserved
PACEMAKER MECHANISMS
IN CARDIAC TISSUE
Dario DiFrancesco
Dipartimento di Fisiologia e Biochimica Generali, Elettrofisiologia, Universita di
Italy
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KEY WORDS: cardiac pacemaker, sinoatrial node, pacemaker current, if current, modulation
INTRODUCTION
The heartbeat is a sign of life, and not surprisingly it has attracted much
interest and curiosity since the early stages of scientific investigation. Even
Leonardo da Vinci, in his anatomical studies, realized that rhythmic, restless
activity was an intrinsic property of cardiac muscle (92), "As to the heart: it
moves itself, and doth never stop, except it be for eternity." In fact, a search
for the basis of spontaneous cardiac activity could only be undertaken several
centuries after these primitive observations with the development of techniques
that allowed the study of the electrical properties of excitable tissues and
particularly of cardiac muscle (18, 71,77,23).
Cardiac pacemaker activity originates in specialized myocytes located in
restricted areas of the heart that are characterized by the ability to beat
spontaneously even when separated from the rest of the cardiac muscle (24,
106, 103, 11, 81). Voltage-clamp investigation of pacemaker tissue opened
the way to a better understanding of the ionic mechanisms promoting
rhythmicity in pacemaker tissue (64, 6). In pacemaker cells of the mammalian
sino-atrial (SA) node, spontaneous activity results from a typical phase of
their action potential, the slow diastolic depolarization. The concept that a
slow depolarization is an inherent property of spontaneously active myocar
dium is an old one that has been actively investigated since the first recordings
of cardiac electrical activity revealed the existence of a slow depolarizing
phase preceding the action potential onset in beating tissue (for a review, see
105). During this phase, corresponding to diastole of the cardiac contraction
cycle, the membrane slowly depolarizes following termination of an action
potential, until threshold for a new action potential is reached. Thus, the
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456 DIFRANCESCO
illustrated in Figure 1. Here three traces, recorded from a sino-atrial node cell
in normal Tyrode solution and in the presence of either isoprenaline 10 nM
or acetylcholine 3 nM, are superimposed. Clearly, under these conditions
neither drug significantly alters action potential shape or duration, and changes
in the spontaneous frequency are entirely due to effects on the duration of
diastolic depolarization. This means that, at least at these low neurotransmitter
concentrations, autorhythmicity is controlled by the rate of development of
the pacemaker phase. What is the ionic basis of the diastolic depolarization?
As any depolarizing process requires a net inward ionic flow, we expect to
find at least one inward current activated in the pacemaker range of voltages
that is able to drive the diastolic depolarization. In this review we consider
the current experimental evidence for the mechanisms underlying generation
of autorhythmicity in cardiac cells and its control by l3-adrenergic and
muscarinic stimulation. As is discussed below, among the various components
present in SA node cells, the hyperpolarization-activated (ir) current appears
to be most specifically designed to initiate the development of a slow
depolarizing process in the diastolic range and to control its rate of rise in
response to neurotransmitter-induced modulation.
200 ms control
I
ISO 10 nM
mV
-50
The iK2 re-interpretation was made possible by two independent findings: (a)
K+ -depletion processes could distort the time-course of currents during voltage
clamp in Purkinje fibers to the extent of inducing a fake current reversal near
the K+ equilibrium potential (40, 27); (b) a newly found pacemaker current
carried by Na+ and K+, inward and activating on hyperpolarization in the SA
node (if or ih current) (10, 107) shared several properties in common with i K2
(41). The new interpretation (for reviews see 29. 78. 30) accommodated
several results that could not be explained previously, such as the disappear
ance of the iK2 current in Na+ -free solutions (75), hardly a property of a pure
K+ current, and the fact that the reversal potential was too negative for a K+
current (22). Interestingly, the re-interpretation was not only able to correctly
account for the diastolic depolarization of Purkinje fibers, but also to explain
458 DIFRANCESCO
the early conductance measurements that had led to the K+ current decay
hypothesis (37).
As in Purkinje fibers, involvement of a K+ current decay mechanism in
the generation of rhythmic activity had bcen proposed in depolarized frog
atrium (7) and in the frog sinus venosus (11). In frog atrium, rhythmic
behavior was not spontaneous, but was evoked by an externally applied
depolarizing current (inward from the cell's point of view), and since no
outward component can generate a depolarization, in this experimental
arrangement, the applied current acted as the proper pacemaker current. In
the frog sinus venosus an inward current activated on hyperpolarization was
Annu. Rev. Physiol. 1993.55:455-472. Downloaded from www.annualreviews.org
to the pacemaker depolarization (11). This current was later found to have
the same properties as if in the mammalian SA node, and its participation
in pacemaking is still debated (2).
hypothesis does not exclude that iK decays during the diastolic depolarization;
it simply assumes that the diastolic depolarization is not initiated by the
unmasking of a background inward current (passive mechanism), but by
activation of it (active mechanism). In the following we outline the main
properties of the ionic components of SA node myocytes that are activated
within the range of diastolic potentials and discuss their possible role in
pacemaker depolarization.
of the ir threshold in single cells may yield values more negative than the real
ones. This is because run-down quickly reduces the amount of if measurable
on voltage clamp by first displacing the current activation curve to more
negative voltages, and then by decreasing its fully activated amplitude (36).
Together with run-down, other factors like incomplete series resistance
compensation (33) may contribute to the underestimation of the size of if,
Furthermore, if activation kinetics are slow at depolarized voltages (39) and
require correspondingly long steps for complete activation, or proper JJV curve
protocols. Measurement of the activation curve with steps of fixed 0.5 to 3
sec duration, for example (76, 25, 102), may lead to incomplete current
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threshold of about -50 mV (67). It was originally proposed that this current
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remains to be clarified.
The nature of the net background (time-independent, instantaneous) current
in SA node is still uncertain (26). In the absence of direct experimental
evidence, a background component, inward in the pacemaker range and
Na +-dependent, has often been assumed and included in the reconstruction
of nodal electrical activity, on the basis of indirect evidence extrapolated from
data in other tissues and for consistency with previous models (38, 79, 13).
As mentioned above, the presence of an inward background component is a
necessary requirement of the iK-decay hypothesis.
Recently, aNa + -dependent current has been reported in SA node myocytes
on the basis of ion-substitution experiments (66). According to these results,
theNa + -dependence of the background component would supply some 50 pA
in the diastolic range. This value far exceeds the few pA required for the net
diastolic current (see above). Furthermore, to reconcile these data with
previous evidence that no net inward current is recorded down to about -65
mV in beating cells (33), an additional, nearly equivalent background K+
conductance must also be assumed. This agrees with the fact that the same
background conductance is reported to have a K+ permeability much larger
than that to Na + (55). The balance between inward and outward background
components in the diastolic range might provide the conditions that facilitate
initiation of the diastolic phase by activation of even small amounts of a
time-dependent inward current like if.
Sympathetic Modulation
l3-adrenergic stimulation has several actions on ionic currents participating in
the generation of electrical activity of SA node cells. Stimulation of the Ca2+
current has been reported in multicellular preparations (10, 82) and in single
myocytes, where only the L-component appears to be modulated (54). As in
ventricular myocytes (86, 68), activation of adenylyl-cyclase and cAMP
production are involved in this action. This is indicated, for example, by
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Parasympathetic Modulation
One of the first phenomena investigated by microelectrode recording in cardiac
tissue, the action of vagal stimulation on heart rate, was shown in early studies
to be associated with membrane hyperpolarization and an increased K+
permeability (62, 19, 24, 63). A K+ current activated by ACh (iK,Ach) has
been described in both amphibian and mammalian heart, and its properties
have been characterized in detail in intact cardiac tissue (52, 98, 5 0 84),
,
0.01-0.03 fLM, ACh acts selectively on if. Since at these doses ACh is indeed
effective at slowing spontaneous rate, the ir inhibition appears to play a key
role in the vagal control of rhythm. The notion that slowing is caused by
inhibition of the inward if current, rather than activation of a K+ conductance,
agrees with the evidence shown in Figure 1 that slowing caused by low ACh
concentrations or moderate vagal stimulation occurs without membrane
hyperpolarization (61).
There is substantial evidence that the Ca2+ current is inhibited by ACh in
various cardiac preparations (57). The ci+ current of intact SA node has
been reported to be "remarkably insensitive" to ACh (84), although a
significant reduction of basal current can sometimes be observed in single
cells (45, 8). In experiments where ir and i Ca,L were recorded simultaneously,
we have repeatedly observed that 0.03 fLM ACh substantially inhibits if, but
does not modify ica.L (34). In a study done in the range 0.01 to 300 fLM, we
have observed that the threshold ACh concentration, which reduces ica,L by
a measurable amount, is 0.1 fLM in single nodal myocytes. Even at 300 fLM
ACh, iCa.L can be maximally reduced by about only 30% «D. DiFrancesco
et aI, unpublished data). These data rule against a major role for Ca2+ currents
in ACh-induced slowing, even at relatively high ACh doses.
iK,Ach current in atrial cells (88, 4, 70, 110, 72). This mechanism, in which
channel regulation occurs across the membrane without the involvement of a
diffusible intracellular second messenger, may be especially relevant to
beat-to-beat regulation of cardiac performance. There seems to be general
agreement that a subunits of the G protein controlling the ACh-activated
channel (GK) are directly involved in channel opening, and !3'Y subunits may
control channel performance via activation of phospholipase A2 (5, 69, 3).
+
The presence of a fast, direct, G protein-mediated modulation of the Ca2
current reported in other cardiac preparations (111, 95) has not been
investigated in the SA node.
Annu. Rev. Physiol. 1993.55:455-472. Downloaded from www.annualreviews.org
CONCLUSIONS
ters, the inward current should increase during l3-adrenergic stimulation and
decrease during cholinergic stimulation.
The it current is the only current system displaying all the above features
in SA node myocytes. Indeed, its peculiar property of being an inward current
activated on hyperpolarization in the diastolic range is by itself clearly capable
of generating a depolarizing process following action potential repolarization.
Furthermore, the ability to generate a slow depolarizing process is best
achieved by a slow time-dependent activation process, which allows the
development of a constant current flow during a de olarization. Notice that
r
inward currents activated on depolarization (e.g. Ca + and Na + currents) are
apt to underlie regenerative, all-or-nothing depolarizing processes in a
positive-feedback fashion, rather than slow, controlled depolarizations. For
this reason these latter components are responsible for generation of the fast
depolarizing phase of the action potential. Finally, if is modulated in opposite
ways by l3-adrenergic and cholinergic stimuli via a cAMP-dependent,
phosphorylation-independent pathway that allows a fine rhythm control by
the autonomic nervous system. The key element in the pacemaking process
and its modulation by moderate neurotransmitter concentrations thus appears
to be the position of the if activation curve on the voltage axis: the more this
curve is shifted to the right, the more if current will be available for a faster
diastolic depolarization. Since the position of the if activation curve is
controlled by cAMP, the diastolic rate can be finely tuned by the opposite
actions of l3-adrenergic and cholinergic transmitters to achieve the desired
autorhythmic rate.
ACKNOWLEDGMENTS
This work was supported by the Consiglio Nazionale delle Ricerche
(CT90.03303) and the Ministero dell' Universita e della Ricerca Scientifica
e Tecnologica. I thank Dr. Richard B. Robinson for comments on the
manuscript and·Prof. Denis Noble for translating Leonardo into Shakespearean
English.
468 DIFRANCESCO
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