Cardiac pacemaker

The contraction of cardiac muscle (heart muscle) in all animals is initiated by electrical impulses known as action potentials. The rate at which these impulses fire controls the rate of cardiac contraction, that is, the heart rate. The cells that create these rhythmic impulses, setting the pace for blood pumping, are called pacemaker cells, and they directly control the heart rate. They make up the cardiac pacemaker, that is, the natural pacemaker of the heart. In most humans, the concentration of pacemaker cells in the sinoatrial (SA) node is the natural pacemaker, and the resultant rhythm is a sinus rhythm. The contraction of cardiac muscle (heart muscle) in all animals is initiated by electrical impulses known as action potentials. The rate at which these impulses fire controls the rate of cardiac contraction, that is, the heart rate. The cells that create these rhythmic impulses, setting the pace for blood pumping, are called pacemaker cells, and they directly control the heart rate. They make up the cardiac pacemaker, that is, the natural pacemaker of the heart. In most humans, the concentration of pacemaker cells in the sinoatrial (SA) node is the natural pacemaker, and the resultant rhythm is a sinus rhythm. Sometimes an ectopic pacemaker sets the pace, if the SA node is damaged or if the electrical conduction system of the heart has problems. Cardiac arrhythmias can cause heart block, in which the contractions lose any useful rhythm. In humans, and occasionally in animals, a mechanical device called an artificial pacemaker (or simply 'pacemaker') may be used after damage to the body's intrinsic conduction system to produce these impulses synthetically. One percent of the cardiomyocytes in the myocardium possess the ability to generate electrical impulses (or action potentials) spontaneously. A specialized portion of the heart, called the sinoatrial node (SA node), is responsible for atrial propagation of this potential. The sinoatrial node (SA node) is a group of cells positioned on the wall of the right atrium, near the entrance of the superior vena cava. These cells are modified cardiomyocytes. They possess rudimentary contractile filaments, but contract relatively weakly compared to the cardiac contractile cells. The pacemaker cells are connected to neighboring contractile cells via gap junctions, which enable them to locally depolarize adjacent cells. Gap junctions allow the passage of positive cations from the depolarization of the pacemaker cell to adjacent contractile cells. This starts the depolarization and eventual action potential in contractile cells. Having cardiomyocytes connected via gap junctions allow all contractile cells of the heart to act in a coordinated fashion and contract as a unit. All the while being in sync with the pacemaker cells; this is the property that allows the pacemaker cells to control contraction in all other cardiomyocytes. Cells in the SA node spontaneously depolarize, ultimately resulting in contraction, approximately 100 times per minute. This native rate is constantly modified by the activity of sympathetic and parasympathetic nerve fibers via the autonomic nervous system, so that the average resting cardiac rate in adult humans is about 70 beats per minute. Because the sinoatrial node is responsible for the rest of the heart's electrical activity, it is sometimes called the primary pacemaker. If the SA node does not function properly and is unable to control the heart rate, a group of cells further down the heart will become the ectopic pacemaker of the heart. These cells form the Atrioventricular node (or AV node), which is an area between the left atrium and the right ventricle within the atrial septum, will take over the pacemaker responsibility. The cells of the AV node normally discharge at about 40-60 beats per minute, and are called the secondary pacemaker. Further down the electrical conducting system of the heart is the Bundle of His. The left and right branches of this bundle, and the Purkinje fibres, will also produce a spontaneous action potential at a rate of 30-40 beats per minute, so if the SA and AV node both fail to function, these cells can become pacemakers. It is important to realize that these cells will be initiating action potentials and contraction at a much lower rate than the primary or secondary pacemaker cells.