Cardiovascular Block

Electrophysiology of the Heart

Dr Simon Harrison
sharrison@alfaisal.edu
Room S3-76

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Recommended texts for Cardio

Klabunde Levick Mohrman &

Buy or rent from Amazon Heller
FREE
2

https://accessmedicine.mhmedical.com/book.aspx?bookid=2432

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 Important Cardiovascular Equations
Darcy’s Law: F = ΔP / R; Resistance in series: Rtot = R1 + R2 + R3
(where ΔP = MAP – RAP)
Resistance in parallel: Rtot = 1/(1/R1+1/R2+1/R3)
Fick Principle: CO = VO2 / CA-CV

Cardiac Output: CO = HR x SV Compliance: C = ΔV / ΔP

Stroke Volume: SV = EDV – ESV Net Driving Pressure (NDP) = (Pc + πi) – (Pi + πp)
Pc = Capillary hydrostatic pressure
Ejection Fraction: EF = SV / EDV
Pi = Interstitial hydrostatic pressure
Mean arterial pressure: MAP = CO x TPR p = Capillary colloid osmotic pressure
I = Interstitial colloid osmotic pressure
MAP = Pdias + 1/3 (Psys – Pdias)
LaPlace’s Law: T = (Pi-Po) x r
Pulse pressure = (MAP – BPdias) x 3

Pulse Pressure: PP = BPsys – Pdias Reynolds number: Re = vDρ / η

Resistance to flow: R = 8 x n x L /  x r4 PVR = MPAP – PWP / CO

Poiseuille/Darcy equations : F = ΔP x  x r4 / 8 x n x L 3

You must know these formulae as this formula list will not be provided in exams.

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 Cardiac Muscle Physiology - Learning Objectives
1. Describe the different phases of the slow and fast response action potentials in the heart including the ion
channels responsible for the changes in membrane potential as well as transmural differences in ventricular
action potential shape and duration.
2. List the steps in excitation-contraction coupling in cardiac muscle and describe the roles of the individual
components involved in the regulation of calcium.
3. Identify differences and similarities between cardiac muscle and skeletal muscle.
4. Describe the roles of ATP in cardiac muscle contraction and relaxation and the primary energy sources utilized
by cardiac muscle in normal and disease states.
5. Contrast the duration of the action potential and the refractory period in ventricular muscle, a skeletal muscle,
and a nerve. Explain what accounts for the long duration of the ventricular action potential and the resultant long-
refractory period. Describe the advantages of the long plateau of the cardiac action potential and the long
refractory period and explain why cardiac muscle cannot remain in a state of sustained (tetanic) contraction.
6. Describe the relationship between muscle length and force development in cardiac muscle. Describe the
molecular origin of passive, active and total force. Understand the molecular mechanism for this based on the
sliding filament theory. Describe the Frank Starling law and how the resting length of cardiac muscle is set at rest
below the optimal length for tension generation unlike skeletal muscle.
7. Be able to draw the relationship between afterload and shortening velocity in cardiac muscle. On the diagram
show how an increase in contractility or preload changes the relationship between afterload and the velocity of
shortening.
4

Excellent review on SA node anatomy and Physiology:

http://www.cardresp.fmed.edu.uy/Boyett_2010_review.pdf

Supplemental (optional) reading materials:

Physiology. Berne et al.,
Textbook of Medical Physiology, Guyton & Hall
Youtube Videos:
http://www.youtube.com/watch?v=0TU9PgGYhQo
http://www.youtube.com/watch?v=xpR8d9KsUrQ
http://www.youtube.com/watch?v=1KXZ0Tcxozo
http://www.youtube.com/watch?v=v3b-YhZmQu8
http://www.youtube.com/watch?v=OnCo_e2QIAc

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 Conduction & Contractile Cells of the Heart
SA and AV NODE : VENTRICULAR
Pacemaker cells MUSCLE (MYOCYTES):
(modified myocytes), contractile myocardial
which produce the cells, which produce the
slow response action fast response action
potentials potential
1
2
0 3
0 3
4 4

4 4
LO1 5

The heart is autorhythmic i.e. it beats without any nervous system innervation
because of the presence of specialized cells that have intrinsic electrical
(pacemaker) activity. Cells of the sinoatrial (SA) node set the frequency of action
potential generation because they lack a stable membrane potential between
successive action potentials and instead the membrane potential displays a
progressive slow depolarization, called the pacemaker potential during phase
4. The cells of the SA node initiate the action potential at a rate of approximately
60-100 times per minute and as this cell type generates action potentials at a
faster rate than other pacemaker cells present in the heart (e.g. AV nodal cells)
then the SA node is considered to be the primary pacemaker of the heart. This
is caused by a more rapid rate of phase 4 depolarization than in any other
cardiac cell type.
The action potential spreads away from the SA node throughout the atria (to the
left atrium via Bachmanns bundle) at a rate of approx. 1 m/s (as adjacent cells
are electrically coupled via gap junctions) and to the AV node via the internodal
pathway. The conduction velocity through the AV node is much slower (0.05 m/s)
which introduces a delay of approx. 100 ms between atrial excitation and
ventricular excitation. This delay is functionally very important as it allows the
atria to contract before the ventricles are excited which increases ventricular
filling with blood. On emerging from the AV node the action potential (AP)
spreads rapidly down the bundle of His, the left and right bundle branches to the
apex of the heart and then up the walls of the ventricles via the Purkinje fiber
network.

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Generation of action potentials in cardiac
muscle: Automaticity in the Heart

Activation of T-Type Activation of T-Type

Ca2+ channels Ca2+ channels

LO1 6

In this slide you can see that the membrane potential in SA nodal cells is never
stable, but changes continuously. Cells that display these characteristics have
the capacity to act as pacemaker cells and generate action potentials which can
be conducted throughout a tissue. In the case of the heart, these action
potentials spread rapidly away from the SA node and innervate the atrial and
ventricular tissue.

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Ionic gradients across heart cell membranes
Ionic gradients exist for the following ions:

Extracellular: Na+ 140 mM, K+ 5 mM, Ca2+ 2 mM

Intracellular: Na+ 14 mM, K+ 150 mM, Ca2+ 0.0001 mM

Relative permeability to different ions is very important in

influencing the membrane potential
For Na+, ENa = +60 mV (+0.06 V)
For K+, EK = -90 mV (-0.09 V)
For Ca2+, ECa = +130 mV (+0.13 V) LO1 7

So if the membrane was only permeable to sodium (Na+), then the membrane
potential would equal or be very close to the Nernst potential for sodium i.e. +60
mV. If only permeable to potassium (K+) then the membrane potential would be
very close to the Nernst potential for K+ i.e. -90 mV. Similarly for Ca2+,
membrane potential would be +130 mV, i.e. the Nernst potential for Ca2+. It
follows that if the membrane was permeable to say both Na+ and K+, then
depending on the relative permeability to the two ions, you could achieve any
voltage between EK and ENa i.e. between -90 mV and +60 mV. This is what
happens during an action potential. The relative permeability of the membrane to
ions changes generating changes in membrane potential.

If the concentrations of ions change- i.e. the magnitude of the concentration

gradient, then you would need to recalculate the Nernst potential for the new
conditions and therefore membrane potential would also change.

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 Cardiac ion channels
• Many different classes and sub-types of ion channels
• The electrical properties of a tissue depend on which ion channels
are expressed in the membrane.
• In cardiac muscle, the main channels involved in membrane
excitation are for Na+, K+ and Ca2+ ions.
• Some channels are not selective for one particular ion.
• In this case the Nernst or reversal potential of the current will reflect
the relative permeability of all permeant ions. (GHK - Dr Shams).
• Therefore, a channel with mixed but equal permeability for both Na+
and K+ has a reversal potential between the Nernst potentials of
those ions (Na+,+60 mV; K+, -90 mV)
• i.e. -90 x 0.5 + +60 x 0.5 = -45 + +30 mV = -15 mV.
LO1 8

Ions are charged species and so are excluded from the membrane bilayer. To facilitate
their movement across membranes specialized proteins are required- these are called
ion channels and when open, ions can pass through them from one side of the
membrane to the other down their concentration gradient. Most ion channels are
essentially specific for a particular ion but others allow more than one ion to pass
through- the latter are called mixed conductance channels.

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 Cardiac ion channels for Na+
• The fast voltage gated Na+ channel- similar to that found in muscle and
neural tissue
• Opens at negative voltages (e.g. –70 mV) and are voltage gated
• Activates rapidly (opening of m gate) and then inactivates rapidly (slower closure of
h gates) which closes the channel despite the activation gate still being open.

• Na+ enters the cell down its

concentration gradient- this
generates an inward membrane
current.
m • This depolarizes the cell (i.e. makes
h the cell interior more positive).
• Confers a very rapid upstroke to
the action potential
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Large inwardly directed electro-chemical gradient for Na ions and so when

channels open, ions will enter the cell. This takes positive charge into the cell
which will make the interior less negative, i.e. more positive which is called
depolarizing the cell.
REVIEW: the role of the m (activation) and h (inactivation) gates in Na
channel activation and inactivation. Remember BOTH gates need to be
open to allow Na+ entry into the cell.
At the normal resting membrane potential, the activation gate (m gate) is closed
and the inactivation gate (h gate) is open. In this condition the channel is
functionally closed, but can be activated by a depolarization of the membrane
that exceeds threshold potential. In response to such a depolarization the
activation gate (m gate) opens rapidly allowing Na+ ions to enter the cell down
their electrochemical gradient. This depolarization, as well as opening the
activation gate also initiates the closure of the inactivation gate (h gate) but the
inactivation gate closes more slowly than the activation gate opens, so there is
a brief period of time (1-2 ms) during the upstroke (phase 0) of the action
potential when both the activation and inactivation gates are open..

During repolarization of the action potential (phase 3) the inactivation gate (h

gate) is closed but the activation gate is still open. In this condition, Na+ cannot
move through the channel (despite the open activation gate). In this configuration
the channels cannot be reactivated until the resting membrane potential is
achieved (phase 4 in atrial and ventricular tissue) so the channels are in a
refractory state. With completion of repolarization and the re-establishment of the
resting membrane potential, the activation gate closes and the inactivation gate
opens and the channel can then be re-activated and generation of a new action
potential is now possible.

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 Cardiac ion channels for K+
K+ currents are outward and make the cell more negative inside
when they flow (repolarization).
There are 4 different K+ channels (i.e. distinct gene products) in
cardiac muscle which allow outward K+ current to flow at various
times during the action potential (AP).
1) Inward rectifier (Kir 2.1). Confers stable resting potential
2) Transient outward K+ current (Ito) Confers rapid repolarization
3) Rapid component of delayed rectifier K+ current - IKr
4) Slow component of delayed rectifier K+ current - IKs.
Delayed rectifier currents underlie action potential
repolarization LO1 10

Inward rectifier acts as a background K+ channel:

This channel opens at negative membrane potentials and sets the stable
negative resting membrane potential of atrial and ventricular muscle close to the
Nernst potential for potassium. As membrane potential becomes more positive
these channels shut.

Transient outward potassium current

Opens rapidly upon depolarization of the membrane but closes quite rapidly too
so generates a transient repolarizing force in ventricular and atrial muscle.

Delayed rectifier K+ channels: IKr and IKs

Closed at negative voltages.
Open when membrane potential becomes more positive and so these channels
are mainly responsible for the repolarization of action potentials in the heart. IKr
(which activates quite slowly, hence the term delayed) is so termed because it
has a faster inactivation rate than IKs. The IKr current is larger than IKs and so
is the more important current in facilitating repolarization of action potentials.

IKr is encoded by hERG or KCNQ1

IKs is encoded by KvLQT1 or KCNE1

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 Cardiac ion channels for Ca2+
2 types: T-type and L-type- (the latter predominates)
1) T-type (Tiny conductance & Transient openings)
• Found predominately in pacemaker (inc PFs) and atrial tissue (not in
ventricle)
• Open at -55 mV and inactivate rapidly
• Relatively small conductance compared to L-type
2) L-Type (Large conductance and Long Lasting openings)
• Found throughout the heart
• Open at -40 mV and inactivate more slowly than T-type
• Ca2+ enters cell depolarizing membrane (inward current). LO1 11

T type (Cav 3.1) stands for Tiny and Transient Openings of these channels,
which have a small conductance therefore slowly depolarize the cells. T-type Ca
channels are found in the SAN, AVN, atrial tissue and Purkinje fibers. In contrast
L (Cav 1.2) stands for Large and Long lasting openings of the channels which
leads to a greater flux of Ca2+ across the membrane and therefore a more rapid
depolarization. L-type Ca channels are expressed throughout the tissues of the
heart.

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 Mixed conductance channels
Funny current (If ): Confers slow depolarization in pacemaker tissue
• Channels permeable to Na+ and K+, (Erev close to -20 mV)
• Activated by hyperpolarization (i.e. at negative membrane
potentials) and cAMP
• Driving force on an ion = difference between membrane potential and
Nernst potential for that ion
• At membrane potential of -60 mV, driving force for Na+ influx greater
than for K+ efflux
• Therefore net inward Na+ current
• Small conductance channel
LO1 12

If encoded by HCN1-4, Hyperpolarisation activated Cyclic Nucleotide-gated

channels
Small conductance (1pS), activates slowly by hyperpolarization- that was the
reason it was called the funny current as all other currents discovered at that time
were activated by depolarization. Expressed in nodal and Purkinje tissues and
also gated by cAMP. As a small conductance channel when open it only leads to
slow changes in membrane potential.

The driving force for an ion is the difference between the Nernst potential for that
ion and the membrane potential. So consider the Nernst potential for Na+ (+60
mV) and K+ (-90 mV). At a membrane potential of
-60 mV the driving force for efflux of K+ from the cells is the difference between -
90 and -60 mV = 30 mV of driving force.

For Na+ the driving force for influx of Na+ into the cells is the difference between
the Nernst potential for Na+, and the membrane potential. Therefore the
difference between +60 and -60 mV = 120 mV of driving force (i.e. 4 x the driving
force for the exit of K+ from the cell). This is why at negative membrane
potentials when the funny current opens, the current that flows is mainly an
inward sodium current.

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 Sodium/Calcium exchange (NCX)
• Main route for efflux of Ca2+ from the cell
OUT
• 3 Na+ ions enter the cell in exchange for 1 Ca2+ ion
• 3 positive charges enter the cell and 2 positive IN
charges leave
• Electrogenic- generates current.
• Direction of current determined by movement of Na+
• Na+ entry and Ca2+ efflux = inward membrane current
• Na+ removed from the cell by Na+-K+ ATPase

LO1 13

See later slides on excitation-contraction coupling for more information

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 Ionic basis of the SA node action potential
• In SA node, inward rectifier
K+ channels and fast Na +
channels are absent.
• Therefore, these cells do
not have a stable resting
membrane potential during
phase 4.
• Maximum diastolic potential
of approx. -60 mV.
Phase 0 Upstroke
• Slow depolarization or Phase 3 Repolarisation
pacemaker potential towards Phase 4 Period between action
threshold of approx. -40 mV potentials LO1 14
(phase 4).

Phase 0 Upstroke
Phase 3 Repolarisation
Phase 4 Period between successive action potentials

The ionic basis of the AV node is effectively the same as that for the SA node.

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 Ionic basis of the SA Nodal Action Potential (slow response)
0: Upstroke (5 V/s):
• Opening of L-type Ca2+ channels and
Influx of Ca2+
3: Repolarization:
• At +ve voltages opening of
IKr and IKs, efflux of K+, closure of Ca2+
channels
4: Pacemaker potential:
• Closure of IKr and IKs
• Opening of Funny (If) channels and influx
of Na+ (depolarizing)
• At -55 mV opening of T-type Ca2+
channels and when threshold of -40 mV
reached opening of L- type Ca2+ channels
generating upstroke of next AP.
LO1 15

Ionic basis of the SA nodal action potential (AV node essentially has the same
ionic basis)
Nodal cells (or slow response action potentials) are produced primarily by the
pacemaker cells located in the sinoatrial (SA) node and atrioventricular (AV) node) of
the heart. These cells have no true resting membrane potential, rather the most
negative the membrane potential becomes is called the maximum diastolic potential.
SA nodal cells generate regular, spontaneous (automatic) action potentials due to the
phase 4 pacemaker potential described below.
Phase 0 (upstroke 5 V/s) - produced by the opening of voltage-dependent L-type Ca2+
channels (influx of Ca2+)- threshold of -40 mV.
Phase 3 (Repolarization) - produced by the closure of L-type Ca2+ channels and
opening of delayed rectifier K+ channels. There are two types of delayed rectifier K
channels, IKr which activates slowly but inactivates rapidly and is the larger of the two
currents. IKs which activates slowly and inactivates slowly.
Phase 4 (pacemaker potential) – As the membrane potential becomes more negative
due to loss of K+ through IKr and IKs this leads to the closure of these two ion channels
and the opening of funny channels which are activated by the negative membrane
voltage allowing a net Na+ influx which opposes the decaying outward K+ current and
stops the membrane potential becoming any more negative than -60 mV, the so called
maximum diastolic potential (MDP). As the funny current continues to flow, membrane
potential becomes more positive as Na+ continues to enter and at approximately -55 mV
T-type Ca2+ channels also start to open which continues the depolarization until the
threshold of -40 mV is reached and L-type Ca2+ channels open and generate the
upstroke (phase 0) of the SA node action potential. Note that the small increase in
cytoplasmic calcium during phase 4 will also activate Na/Ca exchange to extrude the
calcium which generates a further small inward current carried by sodium.
Re Ca2+ channels: T stands for Tiny and Transient Openings of these channels, which
have a small conductance therefore slowly depolarize the cells. In contrast L stands for
Large and Long lasting openings of the channels which leads to a greater flux of Ca2+
across the membrane and therefore a more rapid depolarization

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 Ionic Basis of Ventricular Action Potential (fast response)
1 2
0 3
4 4
0: Upstroke (200 V/s):
• Opening of fast voltage dependent Na+ channels
and influx of Na+
1: Phase 1 Early Repolarization:
• Opening of transient outward K+ channels (Ito)
and Na+ channels inactivate - Efflux K+
2: Plateau Phase:
• Opening of L-type Ca2+ channels and delayed
rectifier K+ channels (IKr and IKs)- balance
between Ca2+ influx and efflux of K+. Inward
NCX current associated with removal of Ca2+.
3: Rapid Repolarization:
• L-type Ca2+ channels closing but IKr and IKs
continue to flow so efflux of K+ dominates
4: Resting membrane potential:
• Inward rectifier K+ channels open (K+ efflux) to
maintain resting membrane potential. LO1 16

Fast-response (ventricular/atrial myocyte) action potential

The Fast Response (non-pacemaker) action potential is seen in contractile muscle cells (atrial
and ventricular) and is commonly divided into five phases. The start of the action potential looks
like the start of an action potential in a nerve or skeletal muscle cell. However, shortly after the
membrane begins to repolarize, there is a long plateau phase which differs from that of neural
tissue or skeletal muscle.
Phase 0 (depolarization) During phase 0 the cells are most permeable to Na+, and the
membrane potential depolarises towards ENa (+60 mV). Na+ channels inactivate rapidly (1-3 ms)
and then remain closed until membrane potential returns to a negative voltage (-70 mV). As
membrane potential becomes more positive during the upstroke, the inward rectifier K+ channels
shut. This reduces the permeability of the cell membrane to K+.
Phase 1 (early repolarization) - produced by the closure of fast voltage-dependant Na+ channels
and the opening of Transient outward voltage-dependent K+ channels (membrane most
permeable to Potassium- efflux of K+ ).
Phase 2 (plateau) - produced by the opening of voltage-dependant slow L-type Ca2+ channels
(influx of Ca2+); the downward slope during this phase is produced by opening of the delayed
rectifier K+ channels (IKr and IKs, efflux of K+). At this point there is a balance between
depolarizing inward calcium current and repolarizing outward potassium current so there is mixed
conductance to these two ions and therefore the plateau voltage is determined by the relative
permeability to each ion. During the plateau phase the membrane potential changes only slowly.
As a consequence of the increase in Ca2+ in the cells, inward current carried by NCX (which
would be net sodium current- 3Na+ for every 1 Ca2+) also contributes to maintaining the plateau
phase.
Phase 3 (rapid repolarization) - produced by the closure of L-type Ca2+ channels and the
opening of several K+ channels (efflux of K+); the slow delayed rectifier (IKs) and rapid delayed
rectifier (IKr) repolarize the membrane down to about -60 mV when they close but at this negative
voltage the inward rectifier K+ current is now open and this completes the final phase of
repolarization.
Phase 4 (resting membrane potential) – both delayed K+ rectifier channels have closed, but the
inward K+ rectifier channels (efflux of K+) remain open and maintain the resting membrane
potential close to the Nernst potential for K+ (-90 mV).

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Transmural differences in Ventricular AP duration
• Epicardial APs are shorter in duration
than Endocardial APs in ventricles
• Greater expression of Ito in
epicardium
• Gives marked phase 1 repolarization
and spike and dome configuration
• Depolarization spreads Endo to Epi
• Repolarization spreads Epi to Endo

LO1 17

Flaim , Giles , McCulloch American Journal of Physiology - Heart and

Circulatory Physiology. Published 1 December 2006 Vol. 291 no. 6, H2617-
H2629

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 Cardiac Muscle: ARP and RRP
In cardiac muscle, AP duration
(and refractory period or
refractoriness) is approx. as
long as contractile phase so
RRP
summation cannot occur.
For every period of systole,
there is a period of diastole,
during which the heart fills
with blood.
Absolute Refractory Period: Another AP cannot be generated
Relative Refractory Period: Another AP can be generated but
the stimulus required is larger than normal to lead to a propagated AP.
Refractoriness of ventricular muscle is due to a characteristic
of the Fast Na+ Channels LO5 18

Cardiac muscle contractions, in contrast to skeletal muscle, cannot summate because the action
potentials in cardiac muscle are of much longer duration (200-350 msec) and therefore the
refractory period is also much longer. The refractory period is due to a characteristic of the fast
sodium current which inactivates rapidly at the start of the ventricular action potential but does not
become reactivated again until negative membrane potentials (approx -70 mV) are achieved
during the repolarization of the AP. So until this membrane potential is achieved the tissue is
refractory and no further APs can be generated. This period of refractoriness is known as the
Absolute Refractory Period. However, towards the later stages of repolarization an action
potential (AP) can be initiated but a larger than normal stimulus will be required which generates a
smaller than usual AP. This is the period called the Relative Refractory Period (or RRP) since it
is difficult to initiate another action potential during the repolarization period, it is difficult to initiate
another contraction. This means that one contraction cannot build on the previous contraction.
Physiologically this is important because it means that for every contraction period (systole), there
is a resting period (diastole), during which the heart can refill with blood.

1. Absolute refractory period - the period of time during which no action potential can be
initiated, regardless of stimulus strength (ARP in Figure above) and is considerably longer in
duration than observed in skeletal muscle.
2. Effective refractory period, the period of time during which no propagated action potentials
can be elicited regardless of stimulus strength (i.e. an action potential could be generated but it
would not propagate to adjacent tissue).
3. Relative refractory period (RRP) the period of time in which a propagated response can be
elicited but the stimulus required is larger than normal and the amplitude of the action potential is
abnormally small.
4. Supranormal period (SNP): This can occur in circumstances where the ventricular tissue is
more depolarized than normal- a hyper-excitable state and therefore a slightly smaller than
normal stimulus can elicit a propagated response, although the amplitude of the action potential is
reduced compared to normal. This can lead to the generation of abnormally timed action
potentials and ventricular (or atrial) dysrhythmia.

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Intrinsic Pacemaker Activity of the Heart:
Overdrive Suppression
•60–100 bpm  SA Node – normal pacemaker
•40–60 bpm  AV Node
•20–40 bpm  Purkinje System

LO1 19

The cells of the SA node are the first cells in the heart to generate an action
potential and their frequency of firing (60-100 bpm) dominates the frequency of
any other cell, thus they are referred to as the primary pacemaker cells of the
heart. This is due to a more rapid rate of phase 4 depolarization than in any
other cardiac cell type. Since the intrinsic firing frequencies of the secondary
(atrioventricular (AV) node) and tertiary pacemakers (bundle branches and
Purkinje fibers) are slower than the SA node, all the pacemakers end up firing at
the SA node rate, not their own rate because their pacemaker activity will be
reset by the passage of the SA node generated action potential. This rapid firing
of the SA node causes the secondary and tertiary pacemakers to fire faster than
their intrinsic rates. This is called overdrive-suppression. The figure above
shows the time for the spread of an action potential generated in the SA node
throughout the tissues of the heart. Note the different action potential waveforms
in the different tissues of the heart and how these lead to the generation of the
characteristic waves on the ECG (See ECG lecture 1).

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 Attendance
https://elearning.alfaisal.edu/my/

20

20
 Cardiovascular Block

Excitation-Contraction Coupling
Dr Simon Harrison
sharrison@alfaisal.edu
Room S3-76

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Introduction

The architecture of cardiac muscle is very similar to skeletal

muscle.

Repeating unit is the sarcomere, bordered by the Z-disks, incorporating myofibrils, SR t-

tubules, mitochondria, nucleii

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 Ultrastructure of the sarcomere
• The myofilaments are
composed of two sets of
interdigitating filaments.
• The A-bands contain
thick filaments.
• Thick filaments are
composed mainly of the
protein myosin.
• The thick and thin filaments overlap and
• The I-bands contain thin
interdigitate.
filaments.
• Thin filaments attached to Z-disc and
• The thin filaments are
arranged in hexagonal array.
composed primarily of
the protein actin. • Myosin filaments organised by M-line-
also in a hexagonal arrangement.

23
Thin filament structure

• The actin filament has a double stranded rope-like structure.

• Associated with the actin filament is a long protein called tropomyosin.
• This protein lies in the groove made by the two strands of the actin
filament.
• The actin filament has a repeating structure composed of 7 actin
monomers polymerised together and associated with that is one
tropomyosin protein unit.

The long tropomyosin molecules (each 42 nm long) make end on attachments to create
long filamentous strands which lie in the groove of the teo filamentous actin strands.
The troponin structure next slide) is located at the point where adjacent tropomyosin
molecules join. Thus troponin acts to stabilize the tropomyosin structure by the function
of troponin T.

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Thin filament structure

• Every 38.5 nm along the actin-tropomyosin filament there is another

protein complex call troponin.
• The troponin complex is made up of three different subunits:
• Troponin-C (Tn-C) mol. wt, 18,000 Role: binds Ca2+ ions
• Troponin-I (Tn-I) mol. wt, 25,000 Role: binds to actin. Its role is
to inhibit the binding of myosin to actin
• Troponin T (Tn-T) mol. wt. of 42,000 Role: binds Tropomyosin

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 Thick filament structure

• Consists mainly of myosin.

• Individual myosin molecules have a head and a long tail.
• The head is made up of 2 identical sub-units. The heads of the
molecules are known as cross bridges and are the site of ATP
hydrolysis and consequent tension generation.
• The thick filament is made up of ~ 300 individual myosin molecules
packed together.

26
 Thick filament structure

• Each myosin molecule is tethered to the thick filament by its tail

with the head sticking out.
• The myosin molecules are arranged such that the cross bridges
(heads) stick out from the filament in a regular pattern.
• Each thick filament is at the centre of a hexagonal array of thin
filaments.

27
 Titin

• Titin molecules associated with the myosin filament

• They attach to the Z-line and the M-line
• Portion of titin molecule in the bare zone is coiled and acts as a
spring. This confers passive tension at longer sarcomere lengths

In addition to thin and thick filaments, the sarcomere contains the protein Titin, a
long filamentous protein. Titin molecules anchor to the Z-disc and extend to the
M-line region of the sarcomere. The titin molecule is very large and has a coiled
structure, like a spring.

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 Actin-myosin interaction
• Activation of the heart actin
troponin
complex tropomyosin
muscle cells via the
action potential is
transduced into a rise of
Ca2+ in the cytoplasm.
• Ca2+ binds to troponin-
C, which acts as a
molecular switch to
allow cross bridge Myosin thick filament

cycling to occur.

29
 Architecture of the t-tubule/SR
• The t-tubules invaginate the
muscle cells at the level of
the Z-line.
• T-tubules are continuous
with the surface membrane
of the cell.
• Contain extracellular fluid.

• Sarcoplasmic Reticulum (SR) is made up of longitudinal and

terminal elements.
• Terminal cisternae of the SR are located close to the t-tubules.
• This arrangement is crucial for excitation-contraction coupling in
cardiac muscle.

30
 Micro-architecture of the t-tubule
• Terminal cisternae of SR and t-
tubule in close apposition.
• The outside face of the SR is
decorated with the SR Ca2+
release channels – called
ryanodine receptors (RYR) or foot
proteins.
• L-type Ca2+ channels (DHPR) are
located in the walls of the t-tubule.
• The L-type Ca2+ channels are
situated directly over the SR Ca2+
release channels.

31
 Excitation-contraction coupling

Physical connection between No Physical connection between

DHPR and RyR1 DHPR and RyR2
• In skeletal muscle the L-type Ca2+ channels (DHPRs) are arranged in
tetrads over a ryanodine receptor (RYR).
• In cardiac muscle, there are the same number of RYRs as in skeletal
muscle but cardiac muscle has fewer Ca2+ channels and their arrangement
is less well ordered- almost random with respect to the RYRs.
LO2 & 3 32

The Cross bridge cycling mechanism and regulation of contraction is effectively identical in cardiac muscle to that
described previously for skeletal muscle. The role of troponin subunits, tropomyosin and actin myosin interactions in
skeletal muscle as that is also identical to cardiac muscle.

32
 Excitation-Contraction Coupling in Ventricular Muscle
No physical
connection between • 30% of Ca2+
DHPR and RyR
from outside
• 70% released
from SR

LO2 33

The action potential travels across the surface membrane of ventricular cell and down the T-tubules which
are wider than in skeletal muscle (to reduce the prospect of depletion of Ca2+ ions in the T-tubular space.
This will depolarize the T-tubular membrane where the L-type Ca2+ channels (DHPRs; CaV 1.2) are
concentrated. Ca2+ channels are situated directly opposite SR Ca2+ release channels (RYRs) on the surface
of the sarcoplasmic reticulum (SR). Ca2+ entry as a result of the opening of these L-type Ca channels binds
to the RyR (RyR2 in cardiac), inducing an increase in its opening probability so RYRs open and Ca2+ floods
out of the SR into the cytoplasm. The DHPRs are not physically connected to the RYRs as in skeletal
muscle.

Therefore a small amount of Ca2+ crossing the cell membrane via L-type Ca2+ channels causes a larger
amount of Ca2+ to be released, via the ryanodine receptors, from the SR- much like an amplifier. This is
called Ca2+ induced Ca2+ release (or CICR).

In humans, about 30% of the Ca2+ for each contraction comes from outside the cells with the
remaining 70% released from the SR via the RYRs.
Ca2+ can then bind to troponin-C moieties on the actin filament, cross bridge cycling can begin and
contraction occurs. Thin (actin) filament regulation is essentially the same in skeletal and cardiac muscle.
For relaxation to occur to lead to diastole, Ca2+ must be removed from the cytoplasm by one of three
pathways:

1) Ca2+ is pumped back into the SR by ATP-dependent Ca2+ pumps (SERCA2) (70%)
2) Ca2+ is removed from the cell via the Na+-Ca2+ exchanger (NCX) (28%) which generates an inward
membrane current carried by sodium during the plateau.
3) Ca2+ is removed from the cell via the plasmalemmal Ca2+ ATPase (PMCA)(2%).

SERCA2 is regulated by a small protein (52 aa) called phopholamban. Phospholamban can be
phosphorylated by PKA (at serine 16) and CaM kinase II (at threonine 17) and when phosphorylated it
dissociates from SERCA2 and this increases the uptake rate of Ca back into the SR.

It is important that the same amount of Calcium that entered the cells during excitation is removed
from the ventricular cells BEFORE the next contraction otherwise the cells would continually gain
calcium. This is achieved primarily via NCX using the power of the inwardly directed electro-chemical
gradient for Na+ to extrude 1 Ca2+ from the cell against its concentration gradient in exchange for 3 Na+ ions
entering the cell (Normal mode NCX which generates an inward membrane current).

33
 Similarities between cardiac and
skeletal muscle
• Both are striated.
• Interdigitating thin and thick filaments giving
characteristic A and I bands.
• The thin filament regulatory proteins such as
tropomyosin and troponin are present in both muscle
types.
• The cross bridge cycle is also identical to skeletal
muscle.
LO3 34

34
 Differences between cardiac and
skeletal muscle
• T-tubules are wider in cardiac muscle (reduces ionic depletion).
• T-tubules enter the cells at the Z-lines (cf. A-I boundary in skeletal
muscle).
• Mechanism of SR Ca2+ release is different.
• Fewer DHPRs in cardiac than skeletal muscle.
• Ca2+ does not enter cells in skeletal muscle so doesn’t have to be
removed between contractions as in cardiac muscle.
• Skeletal DHPR = CaV 1.1 Cardiac DHPR = CaV 1.2
• Skeletal RyR1 and Cardiac RyR2
LO3 35

No Physical connection between DHPR and RyR as in skeletal muscle

35
Sites of ATP usage
AC

ATP cAMP

LO4 36

Sources of ATP for Muscle Contraction

Ventricular muscle cells are rich in myoglobin and contain a large number of
mitochondria (~30% of a ventricular muscle cell volume is occupied by
mitochondria) which reflects the high energy demands of this tissue. Only 1-2 %
of muscle mass is glycogen which can be used as a source of ATP in the
absence of oxidative phosphorylation (during ischemia).

ATP is used for several molecular aspects of excitation-contraction coupling:

ATP is required to bind to the S1 myosin head (cross bridge) to detach it from its
binding site on actin and the ATP is then hydrolyzed to ADP and Pi returning the
cross bridge to its high energy conformation. ATP is also consumed by two
mechanisms which contribute to the reduction of cytoplasmic calcium and
therefore relaxation of cardiac muscle: SERCA2 and PMCA. Furthermore, the
main route for the extrusion of calcium from the cell is via NCX which relies on
the transmembrane concentration gradient for sodium which is maintained by the
Na+/K+ ATPase. ATP is also utilized by adenylate cyclase (AC) to generate a
very important intracellular second messenger, cyclic AMP. Therefore ATP must
be generated continuously to ensure an adequate energy supply to maintain the
function of cardiac muscle.
Approximately 60–70% of ATP hydrolysis fuels contractile shortening, and the remaining
30–40% is primarily used for the sarcoplasmic reticulum Calcium-ATPase (SERCA-2) and
other ion exchangers (Na/K pump).

36
 Normal Cardiac Metabolism Changes
with Disease
Normal adult
metabolism:
• 60-70% FFA

• 30% carbohydrates

• Changes in
metabolic status and
disease alters
metabolism
LO4 37

Overview of the metabolic network. The energy-yielding substrates (free fatty

acids, glucose, ketones, and amino acids), via specific catabolic pathways,
converge on acetyl-CoA production with subsequent entry into the tricarboxylic
acid (TCA) cycle. The final step of energy transfer is accomplished through
oxidative phosphorylation (OxPhos), supplying >95% of ATP consumed by the
heart. The boxes (in pink) above each metabolic pathway indicate the
pathological and physiological conditions in which the specific substrate becomes
a predominant contributor to metabolism. ATGL indicates adipose triglyceride
lipase; DGAT, diacylglycerol acyltransferase; mCPT1, muscle form of carnitine-
palmitoyl transferase-1; PDH, pyruvate dehydrogenase; ; TAG, triacylglycerol;
and TCA, tricarboxcylic acid.

Cardiac muscle is continuously active and relies mainly on aerobic metabolism

(oxidative phosphorylation) and requires a constant supply of nutrients carried
in the blood. The primary metabolic substrates utilized by the normal adult heart
are free fatty acids (60-70%) and carbohydrates . Lactate is also an important
substrate especially during exercise. Even short periods of interrupted blood flow
as occurs following occlusion of a coronary artery can lead to ischemia (lack of
oxygen) and death of cardiac cells. The heart has a relatively low ATP content (5
mmol/g wet wt) and a high rate of ATP hydrolysis (0.5 mmol /g wet wt/s at rest), thus
there is complete turnover of the myocardial ATP pool approximately every 10 s under
normal conditions. Approximately 60–70% of ATP hydrolysis fuels contractile shortening,
and the remaining 30–40% is primarily used for the sarcoplasmic reticulum Calcium-
ATPase (SERCA-2) and other ion exchangers (Na/K pump).

Good review on cardiac metabolism here for further information:

http://physrev.physiology.org/content/physrev/85/3/1093.full.pdf

37
 Length-Tension Relationship: Preload
Normal 
Total 
working 
4 range
Tension

Tension (kg/cm2)
3

Normal working  2
Tension (kg/cm2)

4 range Total Tension
3
Passive 
1 Active 
Tension
Tension
2 Skeletal
Passive  Muscle
1 0 1 2
Tension Active 
Length (fraction of optimum)
Tension
Titin
0 1 2 Elastin Cardiac Muscle
Length (fraction of optimum) Collagen LO6 38

Relationship between muscle force and muscle length

Similar to skeletal muscle, the relationship between a cardiac muscle stretched length and tension is due to
the cumulative effect of muscle passive and active tension. The total tension in cardiac muscle, however, is
much greater than that in skeletal muscle.
Cardiac muscle cells are connected by intercalated discs to form a hollow organ that rhythmically fills and
empties. During the filling phase of the heart, called diastole, muscle cells are relaxed (cytoplasmic Ca2+ is
very low) and blood entering the ventricles stretches the cardiac cells, increasing the volume of the
chamber. This generates passive tension of which Titin is the greatest contributor. Titin is a long coiled
molecule associated with the myosin filament, analogous to a coiled telephone cable in structure. You can
compare the stretching of the elastic components of cardiac muscle as being like stretching Titin. As long
as there are still loops in the phone cord, it stretches easily. Once the loops are all straightened out, it
becomes much harder to stretch.
Notice that passive tension does not increase much over a wide range of muscle lengths or chamber
volumes, increasing significantly only at the point that the peak of the active force relationship is achieved
(when Titin is almost fully extended). As a consequence, it is quite difficult to stretch cardiac muscle beyond
the peak of the active force relationship. Because the ventricle is a hollow structure, muscle length is
equivalent to ventricular volume, which is equivalent to diastolic volume (the volume during diastole). The
volume in the ventricle at the end of the diastolic phase is called the End Diastolic Volume or the Preload.
The ventricle is enclosed by the pericardium which also reduces the prospect of overfilling of the ventricles.
In the figure above the normal working range indicates the sarcomere length of a normal ventricle at rest,
referred to as the resting length. Cardiac muscle is NOT at its optimal length for active force development
(in fact resting sarcomere length is approximately 1.8 micrometers) i.e. on the rising phase of the length-
tension relationship. (note: If resting cardiac muscle was at its optimal length for active force development,
either an increase or a decrease in sarcomere length would result in a reduction in active force
development). This is very important for cardiac function and is the basis of the Frank-Starling Law. If
venous return to the heart increases then the ventricles fill with a greater volume of blood which stretches
the ventricular tissue. Therefore sarcomere length is increased in the ventricular myocytes and this leads to
the generation of a greater amount of force as more cross bridges are capable of generating force which
increases the strength of cardiac contraction and expels the greater volume of blood from the ventricles.
Furthermore, stretching cardiac muscle leads to an increase in the sensitivity of Troponin C for Ca and the
thick and thin filaments are pulled closer together making cross-bridge attachment more likely.

38
 Length-Tension Relationship: Preload

As EDV increases,
which stretches
ventricular muscle,
stroke volume (which
equates to the strength of
contraction) increases.

This relationship is known as the Frank-Starling law of the

heart- i.e. as the degree of stretch on the heart increases so
does the force of contraction.
LO6 35

39
 What is Afterload?
• Muscle generates active tension to perform work, to lift a load or
pump blood.
• The load the muscle is trying to lift is called the Afterload.
• For the left ventricle, Afterload is aortic diastolic pressure
• This must be overcome before the aortic valve can open and for
blood to be ejected.
• As soon as left ventricular pressure exceeds the Afterload the
aortic valve will open
• Blood will leave the ventricle (ejection phase).

LO7 40

Muscle generates active tension to perform work, that is, lift a load or pump
blood. The load the muscle is trying to lift is also called the afterload. Afterload
is the load the muscle tries to lift by activating the contractile proteins. For the
left ventricle, afterload is the pressure in the aorta that must be overcome so the
aortic valve will open for blood to be ejected from the ventricle. As soon as the
left ventricle has generated sufficient active tension to exceed the pressure in the
aorta (afterload), the aortic valve will open and blood will leave the ventricle.

40
 Force-Velocity Relationship

Vmax Maximum 
shortening
velocity
Vmax when Afterload is zero
Shortening Velocity

Shortening Velocity
limited only by Myosin ATPase

Increasing preload

Fmax

Afterload Maximum 
isometric
Afterload
tension

For a given afterload (i.e. diastolic aortic blood pressure), as you

increase preload (filling) of the heart, you increase shortening velocity.
LO7 41

Relationship between active force and shortening velocity

The force-velocity curve of cardiac muscle resembles that of skeletal muscle and
smooth muscle. It has a theoretical value (V max) for when the afterload is zero.
As in skeletal muscle, this would be limited only by rate of the myosin ATPase. It
also has a theoretical Fmax for when the aortic pressure (afterload) is so high that
the muscle cannot generate sufficient force to open the aortic valve. In normal
physiological circumstances the actual afterload lies between these two
extremes, and cardiac muscle can perform work (shortening while forcibly
ejecting blood into the aorta).

In cardiac muscle the force-velocity curve changes with muscle sarcomere

length, that is, with preload. Remember that normally, the sarcomere length of
ventricular muscle is shorter than the optimal length. As the volume of blood
within the ventricle increases and stretches the sarcomere length (increased
preload), the force-velocity curves shifts up and to the right (i.e. an increase in
Fmax with increased preload). Therefore for any given afterload, as preload
increases the shortening velocity will increase and blood will be ejected faster
because the force of contraction is increased.

41