Comparative Mechanisms for Contraction of
Cardiac and Skeletal Muscle*
Robert]. Adams, Ph.D., and Arnold Schwartz, Ph.D.
The comparison of cardiae and skelefal mUlde strue-
tnre reveals dUierenees which can be relafed to dUier-
enees in die functional cllarac:terls1ia of die two mnsde
types. Examples which are discussed include die sar-
colemma, transverse tnbnles and sarcoplasmic: retlenlum
which serve as major sonttes of contraction-dependent
caldum. Mechanisms by which caldum is made avaD-
able to, and ntilized by the myofibrils is discussed in
relation to die mechanics of mnsde contraction as a basis
for the dlscalon of u:cltatlon-eontradlon eonpllng In
cardiae and skeletal muscle. Ell:chatlon-coatraction con-
pllq in skelefal muscle is COIISidered to be mediated by
a voltage-dependent charge movement within the regloa
of the sarcolemma (f-tnbule): junctional sarcoplasmic
reticulum. Depolarization of die sarcolemma initiates
the charge movement which may result in a change in
sarcoplasmic reticulum membrane potential and ion con-
ductance which is assodated with release of calcium to
The study of mechanisms of cardiac muscle con-
traction has depended heavily upon a compari-
son with structural and functional corre-
lates of skeletal muscle. On the basis of such a
comparison, much progress has been made in under-
standing the nature of myocardial contractility and
the means by which contractility is regulated. Al-
though the central role of calcium in the contractile
process of both cardiac and skeletal muscle is well
established, the cellular mechanisms by which cal-
cium is made available to the contractile proteins
during excitation to elicit contraction of the muscle
remain unclear. The term "excitation-contraction
coupling" ( E-C coupling) has been used to describe
this basic but highly complex process. In recent
years, much attention has been paid to the structural
and functional aspects of muscle which are thought
to participate in E-C coupling. Technical improve-
ments of standard procedures, as well as the use of
novel experimental tools and design have con-
tributed to this detailed analysis and provided for a
greater understanding of several aspects of E-C
coupling.
°From the IJeparbnent of Pharmacology and Cell Biophysics,
UDiversity ofCincinDati College of Medicine, CinciDuati.
Supported by UDited States Public Health Service Granll
POl HL 22619-01 (P. IC) (A.S.) and F32 HL 05802-0!
(R.J.A.).
Reprint requests: Dr. Schf.DtlfU, !31 Bethesda, C~
45267
CHEST, 78: 1, JULY, 1980 SUPPLEMENT MECHANISMS FOR CONTRACnON OF CARDIAC AND SKELETAL MUSCLE 123
the myo&brlls. In cardiae m118de, acltation appears to
be linked to coatractlon by a dUfereDt althoap DOt ma-
tnally esduslve llleC'hanism, ie, by a proc:eiB of calcium
induced-calclmn release. Depolllrization of the cardble
sarcolemma is IIIIIOCiated with an lnlu: of calcium into
the cell which Initiates the release of more calcium from
die sarcoplasmic reticuhun to activate the myoftbrlls.
One major mechanism that Is predominantly active Ia
cardiac mnsde to repJaae esdtation-eontraction cou-
pling Is the adenylate eyclaae-eAMP-proteln . . _ .,..
tem. Cyclic AMP-clependent protein ldnase mediated
phosphorylation of at least three sites within the myo-
cardium have been ldentifted (myo8brils, sarcoplalmlc
retlcahun and sareolenuna) whlcll appar to modulate
myocardial function. 'I1Iele lites, which are the prlmmy
replatory sites of calclmn and m-.-le contraction, may
be sites of major dysfuadlon duriDI cardiae dlle.e.
This review compares major diHerences, as well as
similarities, between cardiac and skeletal muscle
structure and function, with emphasis on myocardial
contraction. In general, cardiac muscle is similar to
skeletal muscle with respect to basic structure and
mechanics of contraction. However, differences do
exist between the two muscle types, eg, the mode of
excitation (initiation of depolarization), gradation
of contractile force, the response to drugs and other
various interventions, and perhaps most significant-
ly, the mechanism(s) of E-C coupling and muscle
relaxation. Throughout this review, attempts will be
made to cite only the most relevant, or in some cases,
the most recent papers or review articles pertaining
to the subject.
STRuCTURE AND FuNcnoN OF MAMMALIAN CARDIAC
AND SKELETAL MUSCLE
The myocardium, like skeletal muscle, represents
a highly specialized structure which is capable of
transforming chemically stored energy into mechan-
ical work. The energy is provided primarily in the
form of adenosine triphosphate (ATP) and the
work is manifested by contraction, ie, shortening
and development of tension. The utilization of ener-
gy and production of work is dependent upon a
process known as excitation-contraction coupling
whereby the muscle is activated by an electrical
depolarization to contract. It is now recognized that
the vital link between excitation and contraction in
muscle is calcium. 1•7
In skeletal muscle, the capacity to contract and
develop tension is modulated primarily by the re-
cruitment of more or less motor units (individually
innervated groups of muscle fibers), ie, the propor-
tion of muscle fibers that are activated can be varied,
thereby varying the amount of tension developed.
However, cardiac muscle does not consist of motor
units; contraction occurs in an ali-or-none fashion
and thus the heart is a "functional syncytium."
Therefore, myocardial contractility is regulated by
the degree of activation of individual muscle fibers
or by the "recruitment" of more actin-myosin cross-
bridges per sarcomere. It is generally considered
that in cardiac muscle, alterations in the cellular
distribution and utilization of calcium ions play a
central role in modulating myocardial contractile
force.~ This section will discuss the cellular struc-
ture and processes involved in regulating muscle
contraction, with particular attention paid to the
relationships between excitation-contraction cou-
pling, cellular calcium regulation and the mechan-

I-BAND H-ZONE I-BAND

MYOFILAMENTS I ACTIN
~~; I~
~

z MYOSIN z
F'IcURE I. Ultrastructure qf a cardiac muscle cell. Mofibrils are arranged in regular arrays of
thick and thin myofilaments enclosed within a sarcolemma (plasmalemma and glycocalyx,
see Fig 3). The sarcomere, which is composed of thick myosin filaments and thinner actin
&laments located between the Z-lines (shown schematically at the bottom) is the functional
unit of the contractile apparatus. The actin &laments, which are attached to the Z-line, extend
toward the center of the sarcomere to the edge of the central H-zone. The myosin filaments,
which are connected at the M-line, extend toward each Z-line and occupy only the region of
the A-band. Therefore, the actin and myosin fi.Jaments overlap, or interdigitate between the
edges of the A-band and the H-zone. The 1-band is occupied only by actin filaments and the
H-zone is occupied only by the myosin filaments. The sarcoplasmic reticulum, a tubular mem-
brane network which surr.ounds the myofibrils, consists of free SR (over the region of the
A-band) and the junctional SR (dilated areas of the sarcotubules that abut on the T -tubules
and the sarcolemma with junctional processes). The T -tubules comprise the transverse tubular
system which invaginates the sarcolemma at the Z-line. Mitochondria are situated beneath the
sarcolemma and between the myofibrils. The centrally located nucleus has an envelope, or
membrane which is continuous with the endoplasmic reticulum. The righthand side of the
cell represents the area of the intercalated disc.

124 ADAMS, SCHWARTZ CHEST, 78: 1, JULY, 1980 SUPPLEMENT

ical nature of muscle contraction.
The structure of striated muscle cells '!~ . ~
described for skeletal muscle9.1° and with-?a: . fe~ .~ ·:
exceptions, the structure of working myocardial
cells has been found to be basically the same. UI,u
Under the light microscope, fixed and stained cells
of the working myocardium ( eg, the muscle special-
ized for contraction as opposed to the Purkinje fibers
or nodal cells which are specialized for conduction
and pacemaker activity) appear as numerous fibers,
each enclosed in a plasma membrane, or sarco-
lemma. The myofibers are connected to one another
end-to-end by tight junctions known as intercalated
discs. The fibers are not simple cylindrical units, but
they bifurcate and connect with adjacent fibers to
form an intricate, three dimensional network. Due to
the shape of the cells, their size varies between 50 to
100 ,an in length and 10 to 20 ,an in diameter. In
contrast, skeletal muscle cells appear as long parallel
and rather uniform fibers (grouped into fasicles)
which range from 10 to 100 ,an in diameter. The
length of skeletal muscle cells is quite variable, de-
FIGURE 2. Ultrastructure of a skeletal muscle ceU. Skeletal
muscle has the same essential ultrastructure as that of a
cardiac muscle cell, with the following major differences.
The T-tubules invaginate the sarcolemma at the level of the
A-1 band junction and the junctional SR form large lateral
cisternae which abut on both sides of large segments of the
T-tubules, forming triads. The free SR form a fenestrated
"collar" or M rete, at the level of the M-line, similar to the
free SR of myocardium. Also, at the level of the Z-line there
is fenestrated, free SR known as the Z-rete. Unlike cardiac
muscle, skeletal muscle has numerous nuclei which are gen-
erally located beneath the sarcolemma (not shown). The con-
tractile proteins are of the same structure and orientation as
in cardiac muscle, and the sarcolemma of both muscles is
similar. See Figure 3 for details of membrane structure. (Fig-
ure courtesy of Sommers and Johnson.u)
CHEST, 78: 1, JULY, 1980 SUPPLEMENT MECHANISMS FOR CONTRAcnON OF CARDIAC AND SIW.ETAL MUSCLE 125
pending upon the muscle type, but may extend the
whole length of the muscle.
The predominant features of both types of myo-
fibers (Fig 1 and 2) are the myofibrils contained
within, and filling the sarcolemma. The myofibrils
appear as bundles of thin longitudinal elements
which have a characteristic repeating pattern of
light and dark transverse bands, giving the fiber a
striated appearance. Other predominant structures
within the myofiber include numerous mitochondria,
a centrally located nucleus in cardiac or numerous
nuclei in skeletal fibers which are generally located
at the periphery just beneath the sarcolemma, an
extensive internal membrane system (sarcoplasmic
reticulum or SR) and tubular invaginations of the
sarcolemma (the transverse tubule system or T-
tubules).
The sarcolemma of both cardiac and skeletal mus-
cle is comprised of at least three distinct layers when
viewed with an electron microscope. The plas-
malemma, usually referred to as the sarcolemma, is
the basic cell unit membrane, having a bilayered
structure of about 7-9 nm thickness. On the exterior
of the plasmalemma is a rather homogeneous layer
of material (about 50 nm thick) known as the glyco-
calyx13 or basement membrane, which is composed
of at least two layers. One layer, termed the surface
coat, is about 20 nm thick and is an extension of the
plasmalemma. A more peripheral layer, known as
the external lamina, is about 30 nm thick and
extends from the surface coat. 14 The chemical com-
position of the glycocalyx (primarily anionic muco-
polysaccharides, glycoproteins and sialic acid resi-
dues) contributes to the negatively charged nature
of the polar head groups of the unit membrane phos-
pholipids to make up an extracellular region with a
high capacity for cation binding, particularly cal-
cium. For instance, removal of the sialic acid
from the glycocalyx by neuraminidase treatment
markedly reduces Ca2 + binding to the cardiac
sarcolemma.16 Thus, the glycocalyx may be a site of
Ca2 + binding and exchange across the cell mem-
brane, at least in cardiac muscle, and may play a role
in E-C coupling. The role of the glycocalyx in ion
exchange in skeletal muscle is less clear than in
cardiac muscle. It is known that Ca2 + and other
divalent cations are required in maintaining the
structural integrity of muscle membranes. For in-
stance, in cardiac muscle, perfusion with a calcium-
free solution results in separation of the external
lamina from the surface coat of the glycocalyx, with
resultant disruption of the membrane's selective per-
meability to Cal+ but not to K+ 16.
The sarcolemma of striated muscle is vesiculated
and indented at regular intervals. The indentations
represent sites of tubular membrane invaginations of
the plasmalemma (and of extracellular space) into
the cell interior and comprise what is known as the
transverse tubular system ( T-tubules) . In cardiac
muscle, the T -tubules invaginate predominantly at
the Z-line of the sarcomere (see below), penetrating
to the center of the myofiber and occasionally bi-
furcate to extend longitudinally between adjacent
myofibrils.12
The T-tubules of skeletal muscle invaginate the
cell at the level of the A-1 band of the sarcomere,
and like that of cardiac muscle, bifurcate horizontal-
ly. The major morphologic differences between the
T-tubules of the two muscle types are that: a) the
lumen of cardiac T -tubules is variable but in general
much greater than that of skeletal T -tubules; b) thP.
T -tubule membrane of cardiac muscle is heavily
vesiculated, contains many membrane bound parti-
cles and includes the glycocalyx of the surface sar-
colemma whereas T -tubules of skeletal muscle lack
SarcoleMMa
CARDIAC MUSCLE CELL
these features; and c) the T -tubules of skeletal mus-
cle have a consistent orientation to the intracellular
sarcoplasmic reticulum ( eg, triads) whereas that of
cardiac muscle is more random in its "internal cou-
plings" to SR (Fig 3).
Contained within and embedded in the phos-
pholipid bilayer of the plasmalemma are numerous
globular macromolecules which have protein and
glycoprotein-like properties. Among the membrane-
bound proteins that have been identified to play
important roles in the regulation of muscle contrac-
tion are a variety of hormone, neurotransmitter and
drug receptor sites, 1&-18 membrane-bound enzymes
such as Na,K-ATPase 111.20 and adenylate cy-
clase,21 •22 and a variety of other small molecular
weight proteins which may have regulatory roles in
the modulation of muscle contraction.23..24 The
identification and characterization of these mem-
brane-bound proteins has depended primarily on
biochemical techniques of isolation and purification,
SKELETAL MUSCLE CELL
Sorcole"'""'

F'Ictnm 3. CeU membrane.t of cardltJc (A. left) and kletol (B, right) muscle ceU.. A schematic
representation (not drawn to scale) of muscle membranes shows the unit membrane structure
of the plasmalemma and sarooplasmic reticulum. Closely applied to the plasmalemma is the
glycocalyx, composed of surface coat and external lamiua layers. Embedded in both the
plasmalemma and sarooplasmic reticulum are typical membrane bound proteins, including
neurotransmitter and hormonal receptors, and cation pumps such as the Na,K-ATPase and
the Ca2•-ATPase. In both muscle types. the junctional sarooplasmic reticulum appears to be
"linked" to the plasmalemma of the T -tubules and the surface membrane by what is known
as junctional or "coupling" process.

128 ADAMS, SCHWARTZ CHEST, 78: 1, JULY, 1980 SUPPLBMENT

combined with histochemical and electron-micro-
scopic analysis. Other properties of the sarcolemma,
which have been characterized primarily by electro-
physiologic techniques, include the well known ·se-
lective, voltage-dependent permeability to ions,
which are thought to traverse the membrane via ion
selective "gates," or "channels."8 •211 •28 These ionic
conduits participate directly in the excitation (de-
polarization) events of both cardiac and skeletal
muscle and since the properties of these channels
can be altered by a variety of hormonal and phar-
macologic substances, the contraction coupled to
excitation can be markedly changed by such inter-
ventions. Schematic representations of cardiac and
skeletal muscle cell membranes are shown in Figure
3, which shows the orientation of sarcolemmal com-
ponents as well as sub-sarcolemmal membranes.
In recent years, much research has been devoted
to the isolation and purification of cardiac as well as
skeletal sarcolemma for the purpose of character-
izing structural and functional components. 18.27-211
Particular attention bas been paid to the sites and
mechanisms involved in drug receptor binding, ion
transport and membrane lipid-protein interactions.
Matsui and Schwartz30 pioneered radio-ligand
(drug) binding studies in the early 1960s using
[3JI]digoxin to label and characterize the cardiac
sarcolemmal Na, K-ATPase. Since that time, num-
erous studies utilizing this same technique have pro-
vided similar information regarding drug and hor-
mone binding sites and the cellular actions resulting
from such interactions. Recently, the use of sealed
vesicles of isolated cardiac sarcolemma bas demon-
strated the electroneutral exchange of Na + and
Ca~+ across the membrane, 31 thus providing direct
evidence of an inherent property of the sarcolemma
which is thought to be involved in Ca2 + efllux from
the myocardium during relaxation and Ca2 + influx
during excitation211 or resulting from alterations of
Na+-K+ pump activity. 32 Thus, the preparation of
purified vesicles of cardiac sarcolemma, highly en-
riched in sarcolemmal proteins but devoid of other
cellular membranes (sarcoplasmic reticulum and
mitochondria) is useful for studies of drug-receptor
(and receptor-receptor) interaction at the molecular
level.
One feature of the cardiac cell which is without a
true structural correlate in skeletal muscle is the
intercalated disc. Although skeletal muscle sarco-
lemma does have certain features of this structure
( eg, nexus, desmasomes, etc) the intercalated disc of
cardiac muscle is specialized and is thought to serve
as a low resistance pathway between adjacent cells
which facilitates electrical current :O.ow during ex-
citation. This structural feature thus gives the myo-
CHEST, 78: 1, JULY, 1980 SUPPLfMENT MECHAIIISMS FOR COITRAcnOII OF CARDIAC AIID SIELETAL MBI.E 121
cardium the characteristic of an electrical, as well as
functional syncytium.
The major iQ.tracellular components of both car-
diac and skeletal muscle cells which participate in
the contraction process include mitochondria, sarco-
plasmic reticulum and the myofibrils. The mito-
chondria within the cardiac muscle cell are more
abundant than in skeletal muscle (55 percent com-
pared with 2-5 percent of cell volume, respective-
ly) .12 Mitochondria of both types of muscle cells are
located beneath the sarcolemma, as well as around
and between the myofibrils, and there is some evi-
dence suggesting that two functionally different
populations of mitochondria may exist, ie, "subsar-
colemmal" and intermyofibrilla.r" types33 although
the findings may simply be artifactual. Usually asso-
ciated with or close to mitochondria are lipid drop-
lets and glycogen granules, both of which contribute
to the energy requirements of muscle which is
primarily dependent upon aerobic metabolism (ox-
idative phosphorylation) by the mitochondria.
Whether or not the mitochondria participate direct-
ly in calcium :O.ux during the E-C coupling process is
controversial, and is discussed in a later section of
this review.
The intracellular membrane system, the sarco-
plasmic reticulum ( SR) of both cardiac and skeletal
muscle, is discontinuous with the plasmalemma, but
continuous with internal membranes such as the
nuclear envelope. 12 The SR of both types of muscle
cells consists of a plexiform arrangement of tubular
elements which surround each myofibril. Myocardial
SR is predominantly of the smooth type although a
small amount of rough SR containing ribosomes is
present. Unlike the SR in skeletal muscle, which is
arranged in a more or less parallel fashion and
anastamose freely in the region of the A-bands, car-
diac SR is connected at virtually all levels of the
sarcomere, and therefore, have a somewhat random
orientation with respect to the axis of the myofiber.
Also, in skeletal muscle the sarcotubules of each
sarcomere are con:O.uent in the region of the A-1
band junction, comprising large caliber channels
known as terminal cisternae. Pairs of parallel termi-
nal cisternae run transversely across the myofibrils in
close apposition to the T -tubules. The three asso-
ciated structures (two terminal cisternae, one T •
tubule) constitute the so-called triad of skeletal
muscle and appear to the '1inked"' by electron-dense
outpouchings of SR membrane known as junctional
processes. In cardiac muscle, the SR terminates in
dilatations of sarcotubules which closely appose the
membrane of the T -tubules and the sarcolemma
( subsarcolemma cisternae) via junctional processes
(Fig 1, also Fig 3). The close structural association
between extracellular space (including the T-
tubules) and intracellular structures such as SR and
myofibrils, implies their close functional association
in the process of E-C coupling.
In both muscle types, the SR juxtaposed to the
peripheral plasmalemma or the T -tubule plasma-
lemma is known as junctional SR ( JSR) and al-
though it has been difficult to show true anatomic
connections between the JSR (terminal cisternae)
and plasmalemma membranes, 12 the two structures
do have a tendency to remain together during isola-
tion by homogenization and preparative centrifuga-
tion. ~M-aS Furthermore, the JSR, when isolated from
the T -tubules, appears to be morphologically differ-
ent &om non-junctional SR, which is called free SR
( FSR). For instance, the membrane compositi9D,
density of particles (proteins) and protein composi-
tion differ and it may be that these differences reJlect
different functional properties."
The function of the SR as the primary regulator of
myoplasmic calcium during the contraction-relaxa-
tion cycle is well established for striated muscle.
Although the precise mechanisms of calcium regula-
tion in cardiac muscle have not been completely
elucidated, it is thought that cardiac SR, like skeletal
SR, acts as the primary locus of calcium storage and
release and serves as a site of E-C coupling-relaxa-
tion modulation. 87"'1 On the basis of studies using
intact muscle, as well as isolated SR, it is known that
SR of both muscle types sequester calcium ions from
the myoplasm (and myofibrils) to initiate muscle
relaxation. Furthermore, in skeletal muscle, SR is the
site of activator calcium release to the myoplasm
during excitation to initiate contraction. In cardiac
muscle, which requires an extracellular source of
activator calcium for contraction, the SR also serves
as a major, but perhaps not the sole contributor of
contraction dependent calcium.41
Both cardiac and skeletal muscle SR contain
a membrane-bound protein, the Ca~+-ATPase,
which constitutes the enzymatic machinery of the
calcium pump. The Ca2 +-ATPase has a very high
afBnity for calcium which allows for rapid rates of
binding and subsequent calcium transport across
the SR membrane during relaxation. It is possible
that reversal of the pump and/ or changes in SR
membrane permeability (or conductance) may
occur when calcium is released to the myoplasm to
elicit contraction.88 •811
Other. major proteins of cardiac and skeletal mus-
cle SR include two calcium binding proteins (one
known as calsequestrin) which are thought to act as
calcium "sinks" or translocators within the lumen Of
SR. Another protein, 5o far found only in cardiac SR,
has been termed phospholamban and is thought to
128 ADAMS, SCHWAm
act as a regulator of cardiac Call+ -ATPase activity
and Call+- transport when phosphorylated by
cAMP-dependent protein kinase.G."
In this laboratory, we have compared the func-
tional parameters of SR isolated from cardiac and
various types of skeletal muscle (including fast, slow
and mixed twitch types) and attempts have
been made to relate some of these parameters to
differences in structure.411-47 The functional param-
eters of primary interest in these studies relate to the
physiologic role of the SR in intact muscle, ie, the
binding, uptake and release of calcium as mediated
by the Ca2 +-ATPase. Using spectrophotometric
methods to monitor Cal+ binding and accumula-
tion, it has been shown that the initial rates of Call+
uptake are generally greater in skeletal muscle than
in cardiac (Fig 4). More recently the use of a
quench-Bow apparatus, which is capable of monitor-
ing Cal+ -ATPase reaction rates (transient state
kinetics) in the millisecond range, has provided data
which relates Cal+ -ATPase activity to the rates of
ATP hydrolysis and rates of enzyme phosphoryla-
tion.4M8 These data established relationships be-
tween twitch speed and rates of muscle relaxation to
the rates of calcium transport for the various skeletal
muscle types compared to cardiac. On the basis of
this and other work &om this laboratory as well as
other laboratories, functional differences between
ATP
~ ',,
\ ....... ____ ·-------------Soleus
---
\\ Cardiac
\\ ~---- --Tibialis
~........"___-.......-.-;:::::::::::::.:::::::......................
.......... Coudofemoralls
•
Co
1----1
20sec
Flc'oBB 4. Calcium blnt:Ung of iBolated 81Jf'C01Jlasmic re-
ticulum of ctJf'dlac (~). tllld llow (IOieul), mlud
{tibitrlU) tllld /tl6f (~) .Ir.eletal mude. Sarco-
p1asmic .reticulum was prepared for each muscle type by
a ,Procedure described by Harigaya and Schwartzn and cal-
cium binding measured by a dual-wavelength spectropholo-
meter utilizing murexide as the Ca~+-indicator." The Ieae-
tion mixture CODBisted of 20 mM TRIS/maleate (pH 6.8),
100 mM KC1, 10 mM MgC11 , 0.3 mM murexide and 2.4
mg sarcoplasmic reticulum protein (fiual volume = 3 ml)
Cal+ binding was initiated with the addition of CaC1 2
(fiual concentration = 0.06 mM) and N&zATP (fiual con-
centration=· 0.33 mM). The curves reftect calcium binding
(downward deftection) to the SR of various muscle types
followed in time by spontaneous release of bound calcium
to the reaction solution. As described in the tert, the initial
rates of calcium binding to skeletal SR are greater than for
cardJacSR.
CHEST, 78: 1, JULY, 1980 SUPPLEMENT
the SR of cardiac and skeletal muscle have been
established.48 A knowledge of the reaction mecha-
nism of cardiac SR provides us with details of rate-
controlling steps which may be of great impc)rtarice
in understanding potential defects in calcium trans-
port in pathologic situations.
The myofibrils of cardiac and skeletal muscle are
the same morphologically, and with a few excep-
tions, the same functionally. The myofibrils are ar-
ranged parallel to the axis of the muscle flber and
are contained in repeating units called sarcomeres.
The sarcomere is delineated by two successive
narrow dark lines known as the Z-lines. The distance
between the Z-lines in resting cardiac muscle is be-
tween 2 and 3 p.m, thus defining the sarcomere
length. Between the Z-lines, the next most distinctive
feature is a dark centrally located region within the
sarcomere known as the A-band (anisotropic, or
birefringent band which rotates polarized light). At
either end of the A-band are more lightly staining
sections known as the 1-bands (isotropic band)
which are bisected by the Z-lines. At rest, when the
muscle is not contracted, the central region of the A-
band has a slightly lower density than the rest of the
myoflbril; this region is referred to as the H-zone. In
its center is a narrow dark line, the M-line, located
precisely in the middle of the A-band. Thus, the
sarcomere, which represents the fundamental
morphologic unit of striated muscle, is defined as the
region between two Z-lines and consists of a single A-
band between two bisected 1-bands (Fig 1).
In recent years, the use of electron miscroscopic
and x-ray diffraction techniques have revealed the
ultrastructure of the myoflbrils,110•11 (Fig 5A). The
cross-striated appearance arises from the arrange-
ment of overlapping thick and thin myofilaments.
The thicker myosin filaments ( 100 nm in diameter,
1.5 p.m long) form a parallel arrangement that ex-
tends throughout the length of the A-band and are
held in register by centrally located connections at
the M-line. The thinner actin filaments (50 nm in
diameter) attach to, and extend 1 p.m from the Z-
line to overlap, or interdigitate with the myosin
filaments. The interditation of the actin and myosin
filaments gives rise to the dense area of the A-band.
Higher magnification electron micrographs of glyc-
erol extracted muscles showed that the peripheral
ends of the myosin filaments are covered with nu-
merous projections. In the overlap region of the A-
band, these projections may be joined to the actin
filaments, forming "cross-bridges· between the thick
and thin filaments.
The less dense area of the 1-band is composed
only of actin filaments, and the H-zone within the A-
band contains only myosin filaments. The widths of
CHEST, 78: 1, JULY, 1980 SUPPLEMENT IIECHAI._ FOR CONTRACTION OF CARDIAC AID SKELETAL MUSCLE 128
the H-zone and 1-band are determined by the de-
gree of actin and myosin overlap, ie, when the myo-
fi.ber is stretched, the H-zone and the 1-band become
wider and when the myofi.ber is contracted, both
regions become narrower. In either case, the width
of the A-band remains the same, meaning that myo-
sin filaments (as do the actin filaments ) do not
change length during muscle contraction and relaxa-
tion. The observation of these features provided the
initial basis for the well known sliding-fllament
theory of muscle contraction.IIO,&l
The sliding-filament theory suggests that contrac-
tion is brought about when the interdigitating thick
and thin filaments slide past each other (without a
change in length of either filament). Shortening of
the muscle fiber and tension development occurs as
the result of cyclic reactions between the projections
of the myosin filaments and active sites on the actin
filaments. Each myosin projection initially attaches
to an actin filament site to form a cross-bridge, then
it moves or contracts, and then releases, being then
in a position to attach to another site immediately
adjacent on the actin filament There are no myosin
heads in the center of the sarcomere ( H-zone), and
since each side of the thick &.lament has polarity, the
movement of the actin filaments is coordinated to
move toward the center of the sarcomere.
The development of the sliding-filament theory,
coupled with the elucidation of the myofilament's
composition and mode of interaction (cross-bridge
formation) has provided for a physical, as well as
chemical basis for muscular contraction. At the pres-
ent time the molecular basis for contraction and its
control can be understood in terms of interactions
between four major proteins which make up the
thick and thin filaments; these proteins are myosin,
-----THICK FILAMENT-----
~·-·
MYOSIN
--- --
HMM S-1
THIN FILAMENT
~~
ACTIN TROPONIN"v
COMPLEX
F'IcuBB 5A. c~ o1 ~. LongitudiDal vtew
of the thick and thin myolilameuts in their JeSted state. The
thick 61ament, delineated by the dashed lines, CODtaiDs DUJDel'•
ous myosin mo1ecules which ue compoeed of light meromyo-
sin ( LMM) and two heavy meromyosin subfragments ( HMM
S-1 and HMM S-!). Tbe thin fllaments ant compriled of doa-
ble stranded fibrous actin and two asaoclated regu)atory pro-
teius, tropomyosin and tropoDiD. Tropcmin is a complez of
three proteiDs: troponiD T, tropoDin I and tropoDin C. See tB&t
for discussion.
actin, troponin and tropomyosin. In oitro as well as
in situ analysis of the interactions between these
proteins has revealed the three major characteristics
of muscle contraction: 1) the occurrence of ATP
hydrolysis and the subsequent liberation of chemical
energy; 2) the alteration of physiochemical proper-
ties that, associated with ATP hydrolysis, result in
muscle shortening and the development of tension;
and 3) the dependence on calcium ion in initiating
and regulating contraction. e.u
The thick myosin Blament, when isolated from the
myofibril, appears as a cylindrical aggregate of long
rods. The central region of the filament is smooth in
comparison to the peripheral ends, which are cov-
ered with numerous short projections (these projec-
tions correspond to the cross-bridges between thick
and thin filaments in intact myofibrils). Further dis-
sociation of the filament reveals individual myosin
molecules, rod-shaped proteins with globular projec-
tions at one end (Fig 5A). Tryptic digestion of the
myosin molecule results in two fragments called
light and heavy meromyosin. The light meromyosin
( LMM) corresponds to the rod-like backbone of the
molecule and the heavy meromyosin ( HMM) com-
prises the segment bearing the lateral globular pro-
jection. Digestion of the HMM with papain pro-
duces two subfragments, a larger globular portion
known as heavy meromyosin subfragment 1 ( HMM
S-1) and a smaller portion derived from the rod,
known as heavy meromyosin 2 ( HMM S-2). The
HMM S-l is comprised of several diHerent poly-
peptide chains, including light subunits, {light
chains) which may regulate the ATPase properties
oftheHMM.
The thin actin myofilaments appear as a double
stranded helix of globular subunits. Each strand is a
fibrous polymer (known as F -actin) made up of
numerous globular protein monomers (known as G-
actin). Associated with the actin molecule and of
primary importance in the regulation of cross-bridge
formation are the proteins tropomyosin and tro-
ponin. These proteins can be distinguished using
electron microscopic analysis which has revealed
that tropomyosin is bound stoichiometrically to F-
actin, running between the grooves of the double-
stranded actin filament. Troponin is found at regular
has been studied a great deal as a primary modulator
of contraction, and it has been demonstrated that
the binding sites for calcium are diHerent in cardiac
and skeletal muscle. u.u
Tropomyosin, in cooperation with troponin, acts
to inhibit cross-bridge formation between myosin
and actin when the muscle is at rest When the
muscle is activated to contract,· calcium ions are
made available to bind with troponin C. In so doing,
130 ADAMS, SCHWAm
intervals (every seven actin monomers) along the
actin filament and in a particular spatial arrange-
ment with tropomyosin. The troponin molecule
exists as a globular complex of three proteins:
troponin I appears to act as an inhibitor of actin-
myosin interaction; troponin T serves primarily to
bind the troponin complex to tropomyosin, and
troponin C acts as a reversible binding site for cal-
cium ions. Troponin C, which has been sequenced,
calcium ions initiate a series of interactions which
allows the myosin cross-bridges to bind and form
actin-myosin complexes (Fig 5B).
The binding of calcium to troponin C appears to
inhibit, or reverse the binding of troponin I to actin.
With calcium bound to troponin, the tropomyosin
molecule undergoes a conformational change from
one which blocks chemical interactions between
myosin and actin to one which promotes it. The
formation of an "'active.. complex of myosin and
actin is dependent upon ATP hydrolysis by HMM S-
1 A TPase (Fig 5B, b). Associated with release of
phosphate-bound energy the actomyosin complex
(a) (b)
RESTING STATE ACTIVATED STATE
(c) (d)
ISOTONIC CONDITION ISOMETRIC CONDITION
FIGOBB 5B. Nature of mteroceion between myofilt.Jments
In .ttlle8 of rest t.md tJCtWoUon under Wotonlc tmd Uo-
metric condaionl. In the resting state (a), the interaction
between myosin and actin is inhibited by the physiochemi-
cal status of the regu)atory proteins. The myosin molecule
is "primed" with ATP during rest. In the activated state
(b), calcium ( CA++) is bound to troponin C, inducing con-
formational dwages in the troponin complex and tropomyo-
sin. ATP is broken down to ADP and inorganic phosphate
( P.) by HMM S-1 ATPase and a crossbridge is formed to
create an active complex of actomyosin. Under isotonic con-
ditions (c), the cross-bridge shifts and phosphate bond
energy is utilized to move the thin filament and cause
shortening of the muscle. No shortening occurs under »
metric conditicms (d), but tension is developed when active
actom)'Oifn complexes are formed.
CHEST, 78: 1, JULY, 1980 SUPPLEMENT
undergoes a positional shift, so that, under isotonic
conditions, movement of the myosin cross-bridge
draws the thin filament toward the center of ~~
sarcomere (Fig 5B, c). AB ATP is delivered to~ aiid
binds to HMM S-1 (the sub&agment containing the
ATPase), there is a dissociation of the cross-bridges
from the actin site. The release of ADP and in-
organic phosphate occurs after a series of conforma-
tional changes associated with the movement of the
myosiri. head to the next actin site. Thus, with each
cross-bridge movement per site, one mole of ATP is
hydrolyzed. AB long as calcium is present (bound to
troponin) the cross-bridges will re-establish them-
selves at a point further along the actin &lament,
resulting in further shortening of the muscle. If the
length of muscle is maintained so that it cannot
shorten, as in isometric conditions, the active acto-
myosin complex is maintained without a shift in the
position of the myosin cross-bridges (Fig 5B, d). In
this state of activation, ATP does not bind to myosin
and the cross-bridge is maintained as long as cal-
cium is present. Under both isotonic and isometric
conditions, relaxation occurs when calcium ions are
removed (via SR sequestration) from the troponin
binding site and ATP is once again bound to myosin
after the release of ADP and inorganic phosphate.
These latter events cause the dissociation of the
actomyosin complex: and reversal of cross-bridge
formation.
MECHANics OF MuSCLE CoNTRAcnoN
During the course of a single contraction, the
physical manifestations of the molecular events out-
lined above can be best described in terms of muscle
mechanics. On the basis of the mechanical proper-
ties described for skeletal muscle,117•58 several con-
ceptual models of contraction mechanics have been
developed for isolated cardiac muscle.se,ao Al-
though the various models differ slightly, most stud-
ies have utilized a three-component model81•82
which is sufficient for a general understanding of the
dynamics of cardiac contraction.83 •84 In this model,
the contractile machinery may be represented by an
active contractile element ( CE) which is arranged
in series with a passive elastic element ( SE); both of
these components being coupled in parallel to
another elastic element ( PE). The CE, which ap-
pears to be freely extensible at rest, generates force
and shortens with activation. During an isometric
contraction, the CE shortens and stretches the SE
although the overall muscle length remains constant
The PE does not directly participate in the contrac-
tion process, but does appear to be of importance in
maintaining the resting length and tension of the
muscle.
CHEST, 78: 1, JULY, 1980 SUPPLEMENT MECHANISMS FOR CONTRACTION OF CARDIAC AND SID.ETAL MUSCLE 131
Although the structural, anatomic locations of all
three elements have not been precisely defined, it is
generally accepted that the CE relates directly to the
thick and thin myo&laments as pointed out by Hill81
and Edman and Nilsson.• However, the mechanical
output of the muscle during a single isometric twitch
does not represent the degree of activity of the CE
during the course of the contraction. The shortening
of theCE takes time, and therefore, the external man-
ifestation of the activity ( ie, tension development),
being dependent on the stretching of the SE, is de-
layed after activation. Furthermore, the stretching of
the SE "dampens'" the force generated by the CE so
that the peak tension developed by the whole muscle
does not equal that of the CE.88 The peak tension of
an isometric twitch occurs only when the tension
exerted by the SE is just equal to the tension under
which the CE will neither lengthen nor shorten
during activation. Under these circumstances, the
peak tension represents the "active state" (AS) of
the muscle at a certain time after the CE has been
activated to contract and maximal AS has been
achieved. More broadly defined, the AS is the degree
of activity or force-generating potential of the CE at
any given moment after excitation of the muscle and
is reflected by the time course and tension develop-
ment of an isometric twitch.
Two aspects of the relationship between AS and
active tension development are of importance in
evaluating the effect of inotropic drugs on myocar-
dial contractility. An inotropic eHect may be
achieved by an alteration of either the intensity (or
degree) of AS, the duration of the AS, or both.
Changes in the magnitude of developed tension and
changes in the rate of tension development ( dTI dt),
as induced by inotropic interventions, have been
directly related with the intensity (or degree) of the
AS. 119•87 Changes in the time to peak tension and
total duration of contraction have been related di-
rectly with alterations in the rate of activation and
time to maximal AS. u.ea, 84 The effects of altera-
tions in the intensity or duration of the AS are not
mutually exclusive, as changes in developed tension
can result from changes in either parameter.
Changes in the AS reflect alterations in the in-
trinsic contractile properties of the muscle and may
occur independently of the type of modifications in
myocardial performance caused by changes in mus-
cle length (length-tension relationship). The rela-
tionship between muscle (sarcomere) length and
active tension development dictates that the degree
of tension development during activation is de-
pendent on the degree of overlap between the thick
and thin myo&laments. With increased length of the
muscle from an initial unstretched state, the degree
of overlap, and consequently, the number of poten-
tially active actomyosin complexes increases. With a
greatel'l number of actomyosin complexes formed,
the tension is increased. Further increases in length
result in a reduction in the amount of active tension
produced, as the optimal degree of myo&lament
overlap is surpassed.
Changes in the developed tension may then occur
as the result of alterations in the intrinsic properties
of the contractile machinery, ie, isometric tension is
dependent upon the degree or duration of activation
of a constant number of potential actin-myosin in-
teractions and is, therefore, independent of muscle
length or shortening. It should be noted that al-
though this model is tenable, its validity is contro-
versial and as yet, unsettled, particularly for cardiac
muscle.88
The molecular mechanisms involved in such in-
trinsic changes, ie, changes in the AS, were first
suggested by Hill in 1938. He speculated that "the
chemical transformations associated with the state
of activity in muscle occur by combination at, or by
the catalytic eHect of, or perhaps by passage through
certain active points in the molecular machinery."
... The state of activity in muscle, as presently con-
sidered, depends upon the interaction between the
actin and myosin filaments and formation of active
actin-myosin complexes ("active points"). There-
fore, at any given fiber length and degree of myo-
&lament overlap, alterations in the state of activity
and changes in tension development depend on the
number and intensity of actomyosin complexes as
well as on the rate and duration of complex forma-
tion. 89 •70 Therefore, the AS can be defined as a
measure of those processes at the contractile element
sites that generate force and shortening. With each
contraction cycle these processes are turned on,
reach a maximum and then are turned oH.
As previously stated, alterations in the availability
and utilization of ionized calcium (Call+; bound or
nonionized calcium = Ca) appear to play the central
role in determining the contractile activity of the
myocardium. Theoretically, changes in the intensity
of the AS (number and intensity of active acto-
myosin complexes) are most easily explained as be-
ing due to the gradations in the amount of calcium
available to the contractile proteins during contrac-
tion. Under isometric conditions, when the number
of potentially active points remains constant, (con-
stant actin-myosin overlap), all the sites may not be
activated by calcium. Changes in isometric tension
and in the degree of AS could then be due to varia-
tions in the utilization of Call+ and thus to varia-
tions in the number of active actomyosin complexes
formed. The rate of activation would depend on the
132 ADAMS, SCHWAm
rate of Call+ delivery to, and utilization by, the
contractile proteins and, in turn, would determine
the dTI dt and time to peak tension. The duration of
the active state and of actomyosin complex forma-
tion would depend on the duration of Call+ utiliza-
tion and availability. The increased duration of these
factors would allow for more time to develop tension
with possible increases in the maximal level of ten-
sion, time to peak tension and total duration of
contraction.
As pointed out by Caputo71 in a recent review,
the time course of a single twitch (Fig 6) is not
always a reliable index of the time course of calcium
availability during contraction. However, the onset
and development of the AS does reflect the rate and
magnitude of increases in myoplasmic Call+ as
measured by intracellular Ca2 +-indicators such as
murexide and aequorin. For instance, the peak of
the Call+ transient as measured by these indicators
in cardiac711 and in skeletal muscle 6.bers73 occurs
simultaneously with the maximal rate of isometric
tension development (dT/dtmu:), which has been
directly related to the intensity of the AS despite the
A. CARDIAC MUSCLE
+20
0
mV
-90
0 200. 400 600
msec
B. SKELETAL MUSCLE
+30
0 ..::.., ,,--,' '
:. I '
.:'' .·.
i .~. "'
mV ''
'
___ ,
: ··..··.............', ........ ..
•I • '
\ ... ___ _
-85
0 100 200
msec
F'.tcoBB 6. Electtomechtmic COUJJ'Ung In ctJrt:lloc and 6lceletal
muscle. Represented is a composite diagram of the relation-
ship between simultaneously recorded transmembrane po-
tentials (wUd Une) and isometric tension development
(closhed Une) to the relative time course o£ myoplaimic Ca2+
concentration (dotted Une. redrawn from data in references
72 and 73). Note different time scales £or the two muscle
types.
CHEST, 78: 1, JULY, 1980 SUPPLBMENT
damping effect or lag phase attributable to the series
elastic element This feature, common to both mus-
cle types, reflects a basic similarity of myo6brillar
activation even though the mode and time cOurse of
excitation and contraction as well as relaxation are
different (Fig 6). Further studies which are able to
establish relationships between excitation, myo-
plasmic calcium transients and tension development
utilizing such techniques will contribute tremen-
dously to the understanding of the E-C coupling
and relaxation processes.
ExcrrATION-CoNTBAcnON CoUPLING:
RoLE OF CALCIUM
The essential role of calcium in the initiation and
development of contraction in heart muscle has be-
come well established since the early experiments of
Ringer• who showed an absolute dependence of
myocardial contraction on an extracellular source of
calcium. It was later reported that in calcium-free
solutions, isolated cardiac muscle retained excitabil-
ity and could initiate and propagate action poten-
tials although contractility was abolishedt.s These
findings established that extracellular calcium acted
as an essential "coupler" of the excitation-contrac-
tion process. In subsequent years a cellular calcium
component in the contraction process was consid-
ered. Liittgau74 and Niedergerke7' 711 postulated that
the calcium needed for contraction was stored in a
speciBc "pool" in the myocardium which was some-
how related to an extracellular compartment; with
each action potential a fraction of the stored calcium
was released to participate in the contractile proc-
ess. Sophisticated studies using radioisotopes and
skinned cardiac fibers have since confirmed that the
distribution of calcium is compartmentalized, and
that the calcium which participates directly in myo-
cardial contraction is derived from intracellular, and
possibly from extracellular sources. 42 •78•77 These
findings indicate that multiple sites are involved in
cellular regulation of the contractile process and that
the effect of positive inotropic agents may involve
modulation of one or more of these sites.
The mobilization of calcium from extracellular
and/ or intracellular sites to the contractile proteins
involves processes modulated by a complex, interact-
ing series of mechanisms that begin with excitation
of the sarcolemma and ends when Cal+ binds to
troponin; this is the excitation-contraction coupling
process.
The present understanding of this process in car-
diac muscle can be summarized as follows. During
the course of a cardiac action potential, depolariza-
tion of the sarcolemma and T -system initiates cal-
cium fluxes which are dependent upon an extracellu-
CHEST, 78: 1, JULY, 1980 SUPPLEMENT MECHANISMS FOR CONTRAcnON OF CARDIAC AND SID.ETAI.IIUSCLE 133
lar calcium source and which result in an increased
concentration of ionized calcium within the cardiac
cell. An increased permeability of the sarcolemma to
calcium during the action potential plateau permits
Ca2 + to move down its concentration gradient from
outside to inside the cell via an electrogenic calcium
mediated currentS.78•78 In addition to the ionized
calcium of the extracellular phase, it is thought by
some that super:6cially-bound calcium of the sar-
colemma is mobilized during depolarization and
participates in the calcium flux associated with con-
traction.a.so,s• The amount of Ca~+ entering the
cardiac cell during the plateau phase of the action
potential is by itself probably insufficient to activate
the myo6laments. Therefore, it has been proposed
that the wave of depolarization and the influx of
calcium may mediate the release of intracellular
stores of bound calcium from the sarcoplasmic
reticulum42 •77 and possibly, under certain circum-
stances, from the mitochondria. 82 •83 The calcium
mobilized from the above sources raises the concen-
tration of ionized calcium above IO'"TM in the area
of the myo61aments, and calcium binding to tro-
ponin then initiates the chain of reactions which lead
to actin-myosin complex formation and contraction
of the myo6brils. Relaxation of the myocardium oc-
curs when the calcium concentration around the
myo6laments is reduced, primarily by an enzymatic
uptake mechanism of the sarcoplasmic reticulum.
In skeletal muscle, beat-to-beat activation of the
contractile elements is essentially independent of
extracellular calcium. Therefore, the mode of E-C
coupling is basically different from that of cardiac
muscle with respect to the sources of activator cal-
cium and the "trigger" by which the calcium is made
available to the myo6laments. The classic studies
of WinegradM-81 provided detailed information
about the source and sequence of Ca2 + movement
during the E-C coupling process. Depolarization of
the sarcolemma promotes the release of Ca2 + (by
some as yet undetermined mechanism, see below)
from the lateral cisternae of the JSR (in the triad
region over the Z-lines and A-bands) which acti-
vates the myo6laments to contract. Relaxation is
initiated as Ca2+ and is sequestered by the longi-
tudinal sarcotubules of FSR (in the region of the A-
band). Once in the lumen of the FSR, it is thought
that calcium may diHuse or be transported to the
JSR for subsequent release during the next de-
polarization. This cyclic nature of Ca1 + fluxes in
skeletal muscle during E-C coupling and relaxation
is regarded as being strictly intracellular and in-
dependent of extracellular calcium.
Although cardiac muscle may have similar intra-
cellular calcium fluxes, . t:!-e details of such a cycle
have not been confirmed. More important to the
question of E-C coupling, however, is the nature of
the coupling mechanism in both cardiac and skeletal
muscle which initiates Cal+ release from the SR.
The most recent advances concerning this critical
link between excitation and contraction have been
achieved with isolated skeletal muscle preparations.
It has been proposed that signal transmission occurs
when depolarization of the sarcolemma (including
T -tubule membrane) results in a voltage-dependent
charge movement within the region of the sarco-
lemma-JSR junction.86•87 This charge (dipole)
movement has been recorded in various types of
skeletal muscle and is thought to result in a change
in the conductance of the SR membrane followed by
Cal+ release. 77 Recently, Kovacs and coworkers86
demonstrated that changes in myoplasmic calcium
transients followed the completion of charge move-
ments in skeletal muscle, suggesting that the two
events may indeed be "coupled."
Depolarization of the SR membrane may occur as
a result of charge movement-mediated changes in
membrane conductance. That depolarization of the
SR membrane occurs has been indicated from stud-
ies using membrane permeant, potentiometric dyes
such as Nile Blue A which fluoresce as a function of
membrane potential. The time course of these intra-
cellular membrane fluorescent signals, in relation to
that of the sarcolemmal action potential and the
time course of twitch tension88 •90 resemble the time
course of intracellular Cal+ transients (onset and
decline) as measured by calcium sensitive probes
such as aequorin. 72•78 It should be noted that these
and other data77 do not provide sufficient informa-
tion as to whether the change in SR membrane
potential is the causative factor for CaB+ release or
rather a consequence of an electrogenic efBux of
Cal+ across the SR membrane.
Although the above proposed mechanism of E-C
coupling for skeletal muscle may also be applicable
to that in cardiac muscle, evidence reviewed in a
recent work by Fabiato and Fabiato77 suggests that
another, although not mutually exclusive mecha-
nism, may be active in the mammalian myocardium,
ie, CaB+ induced-CaB+ release. This proposed
mechanism (primarily based on evidence from ex-
periments using force development of skinned car-
diac muscle as an indicator of calcium availability)
suggests that although the small amount of Ca2 +
entering the cell during depolarization is insufficient
to activate contraction directly, that this trans-
sarcolemmal influx of CaB+ induces the release of a
greater amount of CaB+ from the SR (possibly
from the subsarcolemmal SR and T -tubule asso-
ciated JSR) which would activate the myofilaments.
134 ADAMS, SCHWARTZ
This hypothesis of signal transmission for E-C cou-
pling in cardiac muscle has been questioned on the
basis of its "unphysiologic" model, ie, "whether the
methods used for skinned cardiac cells could induce
in the SR properties that it does not have in the
intact cardiac muscle."" The Fabiatos have, how-
ever, recently reported what they feel to be a direct
release of calcium from SR of skinned cardiac cells
using a calcium-sensitive fluorescent probe as the
indicator of calcium availability.81
Fabiato and Fabiatof2•77 and Endo38 have re-
viewed the data pertaining to the hypothesis of
Cal+ induced-Ca2 + release and provide convinc-
ing arguments that such a mechanism may be active
in cardiac E-C coupling. Recently, experiments per-
formed using isolated cardiac SR vesicles have pro-
vided data to support this hypothesis; by exposing
SR (loaded with CaB+) to varying concentrations
of external CaB+, significant release of luminal
Cal+ has been demonstrated.82,88
Obviously, the sources of CaB+ involved the
myocardial contraction, and the regulation of these
Cal+ sources and active flux during E-C coupling
are of a very complex nature. Although the SR may
be the primary source of calcium which directly
activates the myofibrils above discussed, the concept
of CaB+ induced-CaB+ release does not exclude
the probable importance of a sarcolemmal (or trans-
sarcolemmal) source of Cal+ in coupling the ex-
citation-contraction process. t4,M,IIS In addition to
the probable role a sarcolemmal source of CaB+
plays in the normal beat-to-beat regulation of con-
traction, there is evidence to suggest that the avail-
ability of calcium within this source is altered by
pharmacologic agents which alter myocardial con-
tractility.
For instance, Liillman and Holland98 investigated
41Ca exchange in isolated guinea pig atria under
conditions in which the cardiac glycoside, ouabain,
produced either a positive inotropic effect or con-
tracture. They found that although the increased
contractility was associated with an increase in the
amount of easily exchangeable Cal+ present in the
tissue, total tissue calcium remained constant These
data have been interpreted to suggest that digitalis
may affect the flux of calcium across the cell mem-
brane. The positive inotropic action of cate-
cholamines, which augment intracellular cyclic
AMP, also enhance exchange and uptake of Cal+
in the myocardium. It is now generally accepted that
the effect of many positive inotropic interventions is
associated with, and perhaps ultimately due to, an
enhanced mobilization and availability of exchange-
able, ionized calcium within the myocardium. 8
One other major cardiac organelle, the mito-
CHEST, 78: 1, JULY, 1980 SUPPLEMENT
chondrion, has been considered as a possible site for
intracellular regulation of calcium. Because of ·the
extensive distribution of mitochondria in cardiac
muscle and because of the marked ability of thiS
organelle to accumulate Ca1 +, several investigators
have attempted to define its possible role in the
excitation-contraction process.82•88 There is to date,
however, no convincing evidence that mitochondria
actively participate in normal regulation of cardiac
contractility although it has been stated that the
affinity of mitochondria for Ca1 +, the total binding
and storage capacity, and the velocity of calcium
uptake processes are "theoretically" adequate to ac-
count for relaxation in cardiac muscle. 82•88
The relaxation process of cardiac muscle probably
involves several cellular sites and mechanisms which
mediate excitation-contraction coupling. but relies
predominantly on active sequestration of Cal+ by
the SR very much the same as in skeletal muscle.
The fact that with each beat small amounts of cal-
cium enter the cardiac cell without a longterm rise in
total cellular calcium implies that there must be
some mechanism for extrusion of calcium from the
cell. Calcium effiux from the cell must occur against
a large concentration gradient, ie [Ca 1 +] 1 ~10' 7 to
1()-6 M os [CaH]o~l<r" M, which would require
an active process or a coupled exchange mechanism.
Several investigators have been able to demonstrate
a Na+-ca~+ exchange system which could medi-
ate Ca1 + effiux across the sarcolemma of cardiac
muscle. 78 The energy required by this system for
extruding Ca1 + out of the cell may be provided by
the downhill movement of sodium into the cell along
its electrochemical gradient Reuter78 has charac-
terized this Na +-Ca~+ exchange mechanism as
electroneutral, ie, two sodium ions and one calcium
ion compete for one transport site, or "carrier," on
the inner side of the plasma membrane. The ex-
change direction is dependent upon the relative con-
centrations of extracellular and intracellular Na +
and Ca1 + and is independent of the slow channels
which carry the Ca1 + current This latter character-
istic, ie, reversibility of exchange direction so that
Cal+ may enter the cell when intracellular sodium
is elevated (relative to [Na+]o), has been consid-
ered primarily by Langer" to be an important fac-
tor in the regulation of myocardial contractility and
in the action of several inotropic interventions. It
was demonstrated by Glitsch et al88 that t&Ca influx
increased markedly in guinea pig atria in which
internal Na + concentration was elevated and that
increased contractile force was associated with the
increased intracellular Na + concentration and pro-
portionate to the increased t&Ca influx. Some data
bearing on an in vitro manifestation of this process
CHEST, 78: 1, JULY, 1980 SUPPLEMENT MECHANISMS FOR CONTRACTION Of CARDIAC AND SIEI.ETAL MUSCLE 135
has been demonstrated recently in isolated cardiac
sarcolemmal membranes.11•82 Although not proven,
it has also been suggested that a sarcolemmal bound
Ca1 +-ATPase driven Ca1 +-pump may also par-
ticipate in extrusion of Ca1 + from cardiac muscle
during relaxation.88•100
On the basis of electrophysiologic data, t&Ca Bux
analysis and mechanical studies, the role of calcium
in the excitation-contraction-relaxation process of
cardiac muscle can be summarized as follows: The
primary source of contraction-dependent Ca1 +
probably involves intracellular sites, probably the
suhsarcolemmal cisternae and T -tubule-associated
JSR. Upon depolarization of the sarcolemma, cal-
cium from superficial pools enters the cell and
activates release of Ca1 + from the sarcoplasmic re-
ticulum. The calcium from the SR then binds to tro-
ponin causing contraction. Relaxation occurs when
Cal+ is sequestered by the sarcoplasmic reticulum.
During diastolic recovery, Cal+ may be extruded
from the cell by a Na+-Cal+ exchange mechanism
or by an ATP dependent effiux mechanism, or both.
Factors which alter the excitation-contraction-re-
laxation process alter the regulation of calcium at
one or more of these sites of the myocardial cell.
These alterations serve as the basis for the effects of
physical, ionic and pharmacologic interventions
which alter myocardial contractility.
lb:cuLATION OF MYOCARDIAL FUNCI10N
BY cAMP-DEPENDENT PIIOSPHOBYLATION
Since the discovery of 3'-5'-cyclic adenosine
monophosphate (cAMP) and proposal of the sec-
ond messenger concept by Sutherland and col-
leagues101 there have been continuing investiga-
tions into the role of cyclic nucleotides and protein
kinase catalyzed phosphorylation as modulators of
cellular activity. Krebs and coworkers101 have de-
scribed a "cascade" of regulatory events initiated by
beta-adrenoceptor binding of drugs or hormones
which pertain significantly to modulation of myo-
cardial function. This cascade, and the consequent
sites of cAMP-dependent protein kinase catalyzed
phosphorylation in cardiac muscle are summarized
in Figure 7A. In the cardiac muscle cell, the prime
candidates as regulatory substrates for modulating
myocardial contractility are myofibrillar proteins,
the sarcoplasmic reticulum, and the sarcolemmal
membrane.
Phosphorylation of cardiac troponin I by cAMP-
dependent protein kinase has been demonstrated in
vitro as well as in oioo by several investigators.toa.toe
It has been suggested that troponin I phos-
phorylation (Fig 7B) may play a role in the reg-
ulation of myofibrillar ATPase sensitivity to
 BETA-RECEPTOR
"MESSENGER"
ADENYLATE CYCLASE ADENYLATE CYCLASE

CYCLIC AMP

PROTEIN
~
~
KINASE
~~IN
CYCU~AMP~
KIN~.,
~
-1
(CONTRACTED

BETA-RECEPTOR BETA-RECEPTOR
"MESSENGER" "MESSENGER"
ADENYLATE CYCLASE ADENYLATE CYCLASE

I I

,
CYCLIC AMP
~~ CYCLIC AMP
{} (CONTRACTED
PROTEIN ~KINASE (RELAXED SARCOMERE)
~ ~EWKINM.,-

Fxcrou 7. Poalbls dies of fllflocardiol regulation by cvclic AMP~ p'laoaJ)Jwrvlation.

(A. ..,., left). Binding of catecbol•mines such as norepioephrme (NE) or isoproterenol
(ISO) to the cardiac beta-admaoceptor ( B1 ) stimulates adenyJate cyclase (an effect medi-
ated or facilitated by a signal traDsfer with a "messenger" such as GTP or lipid-protein con-
formatioDal chauges). Stimulation of adenyJate cyclase results in catalysis of ATP to cyclic
AMP which then activates the functional catalytic subnnit (C) of cyclic AMP-dependent
protein kinase which in tum phosphoryJates substrate proteiD& Three sites of cyclic-AMP
dependent phosphoprotein formation ( P) in cardiac muscle include troponin 1 of the myo-
fibrillar thin filament (7B, fiPPB1' right), the sarcoplasmic reticulum protein, phospho]amban
( 7C, lower left) and a low molecular weight protein of the sarcolemma which may modulate
calcium (Ca) transport (ID, lower right). See tmt for discussion of possibJe regulatory roles
of theee cardiac pbosphoproteins

calcium107•108 and thereby modulate the contrac-
tion-relaxation process of cardiac muscle. Further-
more, cAMP-dependent protein kinase mediated
phosphorylation of troponin I as well as of myosin
light chains 1011 has been proposed as sites of action
for some interventions which alter myocardial con-
tractility.
A second major site of cAMP-dependent phos-
phoprotein formation that may be involved in myo-
cardial function is the SR (Fig 7C). One specific SR
site of phosphorylation is a .22,000-dalton protein,
termed phospholamban, whiCh when phosphory-
lated appears to enhance the Ca1 +-ATPase activity
and Ca1 +-uptake by isolated cardiac SR.4B,M.a.uo,ut
A third site of significant myocardial regulation
by cAMP-dependent phosphorylation may be the
sarcolemma (Fig 70). Improved methods of separat-
ing sarcolemmal membranes and proteins from car-
diac muscle (in particular, from SR membrane con-
tamination) have permitted the identification of
several potential sites of phosphorylation including
the Na, IC-ATPase111•111 and at least one low molec-
ular weight protein which may also modulate ion
transport across the sarcolemma.11,14.1111.n•
H these cAMP-mediated changes in protein phos-
phorylation and in function occur in vivo at rates
and degrees sufBcient to actually participate in the
contraction-relaxation cycle they may represent im-
portant regulatory components of cardiac muscle
activity. Furthermore, these substrates may be iden-
tified as potential sites for drug action, as well as
areas that may be affected in certain disease states.

1S ADAIIS, SCHWARTZ CHEST, 78: 1, JULY, 1980 SUPPLEMENT

Further study of their roles and further characteriza-
tion of factors which inftuence these sites will un-
doubtedly provide important information about the
nature of myocardial function. .,. . human skeletal muscle fibers. Nature 1979; 281:145-
ACKNOWLEDGMENT: We dumk Dr. Joachim Sommer for·
permission to use the drawing of skeletal muscle cen (Fig 2).
Dr. Taitzer Wang and Mrs. Jean Tsai for their contribUtion
of data 11resented in Figure 4, and DIS. Earl Wallick, Jim
Potter, JOhn Solaro, Litza Kranias and Professm Dean FraDk-
lin for their critical appraisal of the manuscript. The original
studies cited in this review are supported by grants frcmi the
NIH: POI Ill.. 22619-01, T32 Ill.. 07382-02 and F32 Ill..
05802-02.
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