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• The conduction system is made up of a group of specialized cells whose function is to
generate and conduct an impulse through the heart.

• Cells in the conduction system that initiate an impulses are called pacemaker cells

• When the conduction system is functioning normally, the atria and ventricles contract in
proper sequence so that the heart acts as an effective pump.

• Remember that this system is actually in the heart walls. The SA node initiates the impulse in
a normal heart, transmits the impulse to the AV node through the internodal pathways,

• Lastly the purkinje system encircles the entire ventricles

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Located in the upper right hand corner of the right atrium, just beneath the
opening of the superior vena cava.

The sinus node is the heart’s normal pacemaker

• Upper posterior position of RA

• Natural pacemaker of the heart
• 60-100 bpm
• Blood supply - RCA 50% / Circumflex 50%
• Impulse  LA via Bauchmann’s bundle
• Impulse SA to AV node via 3 internodal tracts

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• Inferior portion of RA, near tricuspid valve

• Blood supply from RCA (90%)

• Can initiate rhythm at a rate of 40-60 bpm

• Responsible for delaying the impulse from the SA Node (delay is ~0.04 sec).
• This delay in conduction impulse allows for synchrony of the ventricles and the
ventricles completely fill before contracting, thus the cardiac muscle can stretch to its
fullest to maximize cardiac output.

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• Should be the only way the impulse travels from the atrium to the ventricles

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• The left and right bundle branches are the main highways to the ventricles.

• They arise at the distal end of the AV node, continue down

into the septum, the bundle divides into the left and right
bundles respectively.

• Right bundle goes down the right side of the interventricular

septum down into the RV

• Left bundle divides into two fascicles :

left anterior fascicle- runs down the anterior portion of the LV
left posterior fascicle- runs to the lateral and posterior portions
of the LV

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• The Purkinje fibers conduct impulses very quickly through the myocardium

• Like the SA node, the AV junction and purkinje fibres have the property of automaticity.
• If the SA node fails = AV junction has the ability to function as a pacemaker (40-60bpm).
• The purkinje fibres may function as a pacemaker, (less then 40 bpm).

• When the SA node fails to fire and another pacemaker takes over, it is called an escape
rhythm.

• The fastest pacemaker at any given moment is the one in control. If that faster impulse never
arrives, the next pacemaker in line will assume that it is now the fastest and should escape its
restraints to become the new pacemaker.

• An escape rhythm originates from a subsidiary pacemaker that takes over when the sinus
node is slowed, blocked or fails

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Lets put this all together, here is a video to help put together we have talked about

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1. Sinus node
2. 40-60 bpm
3. Purkinje fibers/ventricle

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The heart cant pump unless an electrical stimulus occurs first. Generation and transmission of
electrical impulses depend on four characteristics of cardiac Cells.

• Automaticity refers to a cell's ability to spontaneously initiate an impulse. Pacemaker cells

possess this ability.
• Excitability results from ion shifts across the cell membrane and indicates how well a cell
responds to an electrical stimulus.
• Conductivity is the ability of a cell to transmit an electrical impulse to another cardiac cell.
• Contractility refers to how well the cell contracts after receiving a stimulus

Automaticity, excitability and conductivity are properties of the cells of the conduction system.
These cells can initiate and propagate impulses to the contractile cells that respond by
contracting and relaxing. These unique properties enable the heart to pump with reliable,
efficient, synchronized contractions.

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 Diffusion- ions move from hi to low concentration
Active transport- from low to hi concentration, requires energy (ATP), eg-
sodium/potassium pump
(move against concentration gradient)

Although these are very intricate details, electrophysiology lays the foundation for
understanding Dysrhythmias. If there is a disturbance in electrolytes you can see how this affects
the ions in the heart cells, causing rhythm problems.

Cardiac cells are electrically negative on the inside as compared to the outside. Movement of
charged particles (ions) of sodium and potassium into and out of the cell cause changes which
can be picked up by sensors on the skin and printed out as an ECG.

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Start at 2:00-3:20 mins

The sodium potassium pump (sodium potassium ATPase) is an enzyme found in the membrane.

Its job is to move NA+ out of the cell and K+ in the cell against their concentration gradient.

This allows the cell to keep a concentration gradient and generates a resting membrane
potential.

In order to do so, the pump needs energy and therefore it is ATP dependent.
- the pump binds ATP, it can then bind 3 Na+ ions intracellularly.
- Hydrolysis of ATP causes a conformational change and the pump opens towards the exterior
of the cell
- This releases the 3 Na+ ions. On the exterior, it binds 2 K+ ions. The pump has now a greater
affinity for Na+
- So K+ is released.
- The pump binds ATP and the whole process starts again

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The action potential curve shows the electrical changes in the cell.

Notice the rapid depolarization during Phase 0, the slow repolarization during Phase 2 and the
rapid repolarization during Phase 3.

The sodium potassium pump maintains an overall negative electrical charge (-90 mV)

The action potential begins with Phase 4, when the cell is at complete rest and ready for
stimulus. This is reflected on the ECG as the P wave.

Phase 0: the cell receives an impulse from a neighbouring cell and is depolarized. Na+ moves
into the cell rapidly and Ca moves into the cell slowly. This causes contraction of the left
ventricle and is reflected as the QRS on the ECG.

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The action potential begins with Phase 4, when the cell is at complete rest and ready for
stimulus.
This is reflected on the ECG as the P wave.

Phase 0: the cell receives an impulse from a neighboring cell and is depolarized. Na+ moves into
the cell rapidly and Ca moves into the cell slowly. This causes contraction of the left ventricle and
is reflected as the QRS on the ECG.

Phase 1: early, rapid depolarization. Na channels close.

Phase 2: the plateau phase; a period of slow repolarization. Ca++ continues to flow in and K+
continues to flow out. This corresponds with the ST segment of the ECG.

During phase 1 and 2 and at the beginning of phase 3, the cell is in it’s absolute refractory
period. No stimulus can get through no matter how hard it tries….more on this later!

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Phase 3:Rapid repolarization occurs as the cell returns to it’s original state.
The Ca++ channels close; K+ rapidly flows out and the sodium-potassium pump begins to
restore K+ to the inside of the cell and Na+ to the outside of the sell.
This phase corresponds with the T wave on the ECG.

During the last half of this phase the cell is in it’s relative refractory period. If a very strong
stimulus comes along it has the potential to depolarize the cell, which can be a very dangerous
situation for your patient!

Phase 4: This is the resting phase where the cell is ready for anther stimulus. The cell membrane
is impermeable to Na+ and K+ continues to flow out of the cell.

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The word refractory means “resistant to”.

Let’s look at the periods when the cardiac cell resists responding to another impulse.

Absolute Refractory Period

The cell cannot accept another impulse because it’s still dealing with the last one. Absolutely no
stimulus, no matter how strong, will result in another depolarization during this time.
• effective refractory period
• onset of the QRS to peak of the T wave
• will not respond to any stimulus

Relative Refractory Period

• vulnerable period
• down slope of the T wave
• may respond to stimulus if strong enough

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Lead
Displays the electrical activity between a positive and negative electrodes

VECTOR
Is the wave of depolarization (heart is depolarized in a downward and to the left pathway).
Normal vector forces flow top to bottom, right to left
A vector is an arrow that point out the general direction of current flow.
The current of the heart normally starts in the sinus node, which is in the right atrium and
terminates in the left ventricle.

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MOST IMPORTANT!!
If an impulse is moving TOWARDS a POSITIVE electrode----the waveform will be positive, or
UPRIGHT on the ECG
If an impulse is moving AWAY from a positive, or towards a negative--- the waveform will be
negative
If an impulse is moving PERPENDICULAR to the electrodes---the waveform is BIPHASIC

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Lead I is the first of three standard limb leads (I, II, III). Limb leads measure cardiac
depolarization in the frontal (coronal) plane.

• The negative electrode is connected to the RIGHT ARM

• The positive electrode is connected to the LEFT ARM.

When an action potential starts on the right and proceeds toward the left side of the heart, a
positive inflection will be seen in lead one. This holds true for all leads. Whenever a current
proceeds toward a positive electrode or away from a negative, an upright inflection is seen on
the EKG tracing.

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MOST IMPORTANT!!
If an impulse is moving TOWARDS a POSITIVE electrode----the waveform will be positive, or
UPRIGHT on the ECG
If an impulse is moving AWAY from a positive, or towards a negative--- the waveform will be
negative
If an impulse is moving PERPENDICULAR to the electrodes---the waveform is BIPHASIC

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Lead II is used alone quite frequently. Normal rhythms present with a prominent P wave and a
tall QRS.

• The negative electrode is connected to the RIGHT ARM.

• The positive electrode is connected to the LEFT LEG.

In all the limb leads, the electrodes may be positioned close to the torso. For convenience, they
are often placed at the shoulders and hips

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Lead III is the last of the three standard limb leads.

• The negative electrode is connected to the LEFT ARM.

• The positive electrode is connected to the LEFT LEG.

You can see the wave of depolarization is almost perpendicular to the plane of the lead,
therefore the waveform is going neither towards or away from the positive/negative pole. The
waveform will be BIPHASIC.

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These six leads are named V1 - V6.

• The AV node is the point of reference.

• This illustration shows the different views of the heart obtained from each Precordial chest
lead.

• View the electrical activity of the heart from the frontal plane, there are six precordial,
unipolar chest leads. This configuration places six positive electrodes on the surface of the
chest over different regions of the heart in order to record electrical activity.

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