The heart is a muscular organ in humans and other animals, which pumps blood through the blood vessels of the circulatory system.[1] The blood provides the body with oxygen and nutrients, as well as removing metabolic wastes.[2] The heart is located in the middle compartment of the mediastinum in the chest.[3]

In humans, other mammals and birds the heart is divided into four chambers: upper left and right atria; and lower left and right ventricles.[4][5] Commonly the right atrium and ventricle are referred together as the right heart and their left counterparts as the left heart.[6] Fish in contrast have two chambers, an atrium and a ventricle, while reptiles have three chambers.[5] In a healthy heart blood flows one way through the heart due to heart valves, which prevent backflow.[3] The heart is enclosed in a protective sac, the pericardium, which also contains a small amount of fluid. The wall of the heart is made up of three layers: epicardium; myocardium; and endocardium.[7]

The heart pumps blood through both circulatory systems. Blood low in oxygen from the systemic circulation enters the right atrium from the superior and inferior vena cavae and passes to the right ventricle. From here it is pumped into the pulmonary circulation, through the lungs where it receives oxygen and gives off carbon dioxide. Oxygenated blood then returns to the left atrium, passes through the left ventricle and is pumped out through the aorta to the systemic circulation−where the oxygen is used and metabolized to carbon dioxide.[2] In addition the blood carries nutrients from the liver and gastrointestinal tract to various organs of the body, while transporting waste to the liver and kidneys.[citation needed] Normally with each heartbeat, the right ventricle pumps the same amount of blood into the lungs as the left ventricle pumps out into the body. Veins transport blood to the heart, while arteries transport blood away from the heart. Veins normally have lower pressures than arteries.[2][3] The heart contracts at a rate of around 72 beats per minute, at rest.[2] Exercise temporarily increases this rate, but lowers resting heart rate in the long term, and is good for heart health.[8]

Cardiovascular disease (CVD) was the most common cause of death globally in 2008, accounting for 30% of cases.[9][10] Of these deaths more than three quarters were due to coronary artery disease and stroke.[9] Risk factors include: smoking, being overweight, not enough exercise, high cholesterol, high blood pressure, and poorly controlled diabetes among others.[11] Diagnosis of CVD is often done by listening to the heart-sounds with a stethoscope, ECG or by ultrasound.[3] Diseases of the heart are primarily treated by cardiologists, although many specialties of medicine may be involved.[10]

The heart is situated in the middle of the mediastinum behind the breastbone in the chest, at the level of thoracic vertebrae T5-T8. The largest part of the heart is usually slightly offset to the left (though occasionally it may be offset to the right). The heart is usually felt to be on the left side because the left heart is stronger, since it pumps to all body parts. The left lung in turn is smaller than the right lung because it has to accommodate the heart. The heart is supplied by the coronary circulation and is enclosed in the pericardial sac.

The pericardium encloses the heart and also attaches to the mediastinum via the pericardiac pleura, providing anchorage for the heart.[13] The back surface of the heart lies near to the vertebral column, and the front surface sits deep to the sternum and costal cartilages.[7] The two great veins, the venae cavae, and the great arteries, the aorta and pulmonary trunk, are attached to the upper surface of the heart, called the base, which is located at the level of the third costal cartilage.[7] The lower tip of the heart, the apex, lies just to the left of the sternum between the junction of the fourth and fifth ribs near their articulation with the costal cartilages.[7] The right side of the heart is deflected forwards, and the left side is deflected to the back.[7]

The shape of the heart is similar to a pinecone, rather broad at the base and tapering to the apex.[7] A stethoscope can be placed directly over the apex so that the beats can be counted. An adult heart has a mass of 250–350 grams (9–12 oz).[14] The heart is typically the size of a fist: 12 cm (5 in) in length, 8 cm (3.5 in) wide, and 6 cm (2.5 in) in thickness.[7] Well-trained athletes can have much larger hearts due to the effects of exercise on the heart muscle, similar to the response of skeletal muscle.[7]

The heart has four chambers, two upper atria, the receiving chambers, and two lower ventricles, the discharging chambers. The atria are connected to the ventricles by the atrioventricular valves and they are separated by the coronary sulcus. The right atrium receives deoxygenated blood from the body and the left atrium receives oxygenated blood from the lungs. When these contract the blood is pushed into the ventricles, which pump to propel the blood to the lungs and the rest of the body.[7] There is an ear-shaped structure in the upper right atrium called the right atrial appendage, or auricle, and another in the upper left atrium, the left atrial appendage. The right atrium and the right ventricle together are sometimes referred to as the right heart and this sometimes includes the pulmonary trunk. Similarly, the left atrium and the left ventricle together are sometimes referred to as the left heart. These are separated by the posterior interventricular sulcus. The left heart pumps to the systemic circulation and the right heart pumps to the pulmonary circulation.

The cardiac skeleton is made of dense connective tissue as collagen and this gives structure to the heart and forms the atrioventricular septum which separates the right from the left heart, and the fibrous rings which serve as bases for the four heart valves.[15] The cardiac skeleton also provides an important boundary in the heart’s electrical conduction system since collagen cannot conduct electricity. The chordae tendinae attach to the atrioventricular valve cusps. The interatrial septum separates the atria and the interventricular septum separates the ventricles.[7] These septa (dividing walls) develop from the myocardium to form the heart chambers. The interventricular septum is much thicker than the interatrial septum, since the ventricles need to generate greater pressure when they contract.[7]

All four heart valves lie along the same plane. The valves ensure unidirectional blood flow through the heart and prevent backflow. Between the right atrium and the right ventricle is the tricuspid valve. The right ventricle receives blood from the right atrium through the tricuspid valve. This consists of three cusps (flaps or leaflets), made of endocardium reinforced with additional connective tissue. Each of the three valve-cusps is attached to several strands of connective tissue, the chordae tendineae (tendinous cords), sometimes referred to as the heart strings. They are composed of approximately 80 percent collagenous fibers with the remainder consisting of elastic fibers and endothelium. They connect each of the cusps to a papillary muscle that extends from the lower ventricular surface. These muscles control the opening and closing of the valves. The three papillary muscles in the right ventricle are called the anterior, posterior, and septal muscles, which correspond to the three positions of the valve cusps.

Between the left atrium and left ventricle is the mitral valve, also known as the bicuspid valve due to its having two cusps, an anterior and a posterior medial cusp. These cusps are also attached via chordae tendinae to two papillary muscles projecting from the ventricular wall.

These two valves are the atrioventricular valves. During the relaxation phase of the cardiac cycle, the papillary muscles are also relaxed and the tension on the chordae tendineae is slight. However, as the ventricle contracts, so do the papillary muscles. This creates tension on the chordae tendineae, helping to hold the cusps of the atrioventricular valves in place and preventing them from being blown back into the atria.[7]

The semilunar pulmonary valve is located at the base of the pulmonary artery. This has three cusps which are not attached to any papillary muscles. When the ventricle relaxes blood flows back into the ventricle from the artery and this flow of blood fills the pocket-like valve, pressing against the cusps which close to seal the valve. The semilunar aortic valve is at the base of the aorta and also is not attached to papillary muscles. This too has three cusps which close with the pressure of the blood flowing back from the aorta.[7]

Right heart

The two major systemic veins, the superior and inferior venae cavae, and the collection of veins that make up the coronary sinus which drains the myocardium, empty into the right atrium. The superior vena cava drains the blood from above the diaphragm and empties into the upper back part of the right atrium. The inferior cava drains the blood from below the diaphragm and empties into the back part of the atrium below the opening for the superior cava. Immediately above and to the middle of the opening of the inferior cava is the opening of the thin-walled, coronary sinus.[7]

In the wall of the right atrium is an oval-shaped depression known as the fossa ovalis, which is a remnant of an opening in the fetal heart known as the foramen ovale. The foramen ovale allowed blood in the fetal heart to pass directly from the right atrium to the left atrium, allowing some blood to bypass the pulmonary circuit. Within seconds after birth, a flap of tissue known as the septum primum that previously acted as a valve closes the foramen ovale and establishes the typical cardiac circulation pattern.[7] Most of the internal surface of the right atrium is smooth, the depression of the fossa ovalis is medial, and the anterior surface has prominent ridges of pectinate muscles, which are also present in the right atrial appendage.[7]

The atria receive venous blood on a nearly continuous basis, preventing venous flow from stopping while the ventricles are contracting. While most ventricular filling occurs while the atria are relaxed, they do demonstrate a contractile phase when they actively pump blood into the ventricles just prior to ventricular contraction. The right atrium is connected to the right ventricle by the tricuspid valve.[7]

When the myocardium of the ventricle contracts, pressure within the ventricular chamber rises. Blood, like any fluid, flows from higher pressure to lower pressure areas, in this case, toward the pulmonary trunk and the atrium. To prevent any potential backflow, the papillary muscles also contract, generating tension on the chordae tendineae. This prevents the flaps of the valves from being forced into the atria and regurgitation of the blood back into the atria during ventricular contraction.[7]

The walls of the right ventricle are lined with trabeculae carneae, ridges of cardiac muscle covered by endocardium. In addition to these muscular ridges, a band of cardiac muscle, also covered by endocardium, known as the moderator band reinforces the thin walls of the right ventricle and plays a crucial role in cardiac conduction. It arises from the lower part of the interventricular septum and crosses the interior space of the right ventricle to connect with the inferior papillary muscle.[7]

When the right ventricle contracts, it ejects blood into the pulmonary trunk, which branches into the left and right pulmonary arteries that carry it to each lung. The upper surface of the right ventricle begins to taper as it approaches the pulmonary trunk. At the base of the pulmonary trunk is the pulmonary semilunar valve that prevents backflow from the pulmonary trunk.[7]

Left heart

After gas exchange in the pulmonary capillaries, blood returns to the left atrium high in oxygen via one of the four pulmonary veins. Only the left atrial appendage contains pectinate muscles. Blood flows nearly continuously from the pulmonary veins back into the atrium, which acts as the receiving chamber, and from here through an opening into the left ventricle. Most blood flows passively into the heart while both the atria and ventricles are relaxed, but toward the end of the ventricular relaxation period, the left atrium will contract, pumping blood into the ventricle. This atrial contraction accounts for approximately 20 percent of ventricular filling. The left atrium is connected to the left ventricle by the mitral valve.[7]

Although both sides of the heart will pump the same amount of blood, the muscular layer is much thicker in the left ventricle compared to the right, due to the greater force needed here. Like the right ventricle, the left also has trabeculae carneae, but there is no moderator band. The left ventricle is the major pumping chamber for the systemic circuit; it ejects blood into the aorta through the aortic semilunar valve.[7]

The double membrane that surrounds the heart and roots of the great vessels is called the pericardium or pericardial sac.[7] The pericardium, (which means around the heart), consists of two layers: the outer fibrous pericardium and the inner serous pericardium[16] and these enclose the pericardial cavity. The fibrous pericardium is made of tough, dense connective tissue that protects the heart and maintains its position in the thorax.[7] The more delicate visceral serous pericardium consists of two layers: the parietal pericardium, which is fused to the fibrous pericardium, and an inner visceral pericardium, or epicardium, which is fused to the heart and is part of the heart wall. The pericardial cavity, filled with lubricating serous fluid, lies between the epicardium and the pericardium.[7]

In most internal organs, visceral serous membranes are microscopic.[7] However, in the heart, the epicardium is macroscopic. It consists of a simple squamous epithelium called mesothelium, reinforced with loose, irregular, or areolar connective tissue that attaches to the pericardium. This mesothelium secretes the pericardial fluid which reduces friction as the heart contracts.[7] It also enables the heart to move in response to the movements of the diaphragm and lungs.[17]

Surface features

Inside the pericardium, the chambers and a series of sulci are visible. Major coronary blood vessels are located in these sulci. The deep coronary sulcus is located between the atria and ventricles. Between the left and right ventricles are two additional sulci that are not as deep as the coronary sulcus. On the front and back of the heart's surface are the anterior and posterior interventricular sulci.[7] These two grooves separate the ventricles.


The wall of the heart is composed of three layers.[7] From outer to inner, these are the epicardium, the myocardium, and the endocardium.[7]

The middle and thickest layer is the myocardium, made largely of cardiac muscle cells. It is built upon a framework of collagenous fibers, plus the blood vessels that supply the myocardium and the nerve fibers that help regulate the heart.[7] It is the contraction of the myocardium that pumps blood through the heart and into the major arteries.[7] The muscle pattern is elegant and complex, as the muscle cells swirl and spiral around the chambers of the heart.[7] They form a figure 8 pattern around the atria and around the bases of the great vessels.[7] Deeper ventricular muscles also form a figure 8 around the two ventricles and proceed toward the apex. More superficial layers of ventricular muscle wrap around both ventricles.[7] This complex swirling pattern allows the heart to pump blood more effectively than a simple linear pattern would.[7]

The innermost layer of the heart wall, the endocardium, is joined to the myocardium with a thin layer of connective tissue. The endocardium lines the heart chambers and valves.[7] It is made of simple squamous epithelium called endothelium, which is continuous with the endothelial lining of the blood vessels.[7]

Once regarded simply as a lining, evidence indicates that the endothelium may play an active role in regulating the contraction of the myocardium.[7] The endothelium may also regulate the ongoing growth patterns of the cardiac muscle cells. The endothelins it secretes, create an environment in the surrounding tissue fluids that regulates ionic concentrations and states of contractility.[7] Endothelins are potent vasoconstrictors and establish a homeostatic balance with other vasoconstrictors and vasodilators.

Cardiomyocytes like all other cells need to be supplied with oxygen, nutrients and a way of removing metabolic wastes. This is achieved by the coronary circulation. The coronary circulation cycles in peaks and troughs relating to the heart muscle relaxing or contracting.[7]

Coronary arteries shown in red and other components in blue. Coronary arteries supply blood to the heart and the coronary veins remove the deoxygenated blood. There is a left and a right coronary artery supplying the left and right hearts respectively, and the septa. Smaller branches of these arteries anastomose, which in other parts of the body serve to divert blood due to a blockage. In the heart these are very small and cannot form other interconnections with the result that a coronary artery blockage can cause a myocardial infarction and with it, tissue damage.[7]

The great cardiac vein receives the major branches of the posterior, middle, and small cardiac veins and drains into the coronary sinus a large vein that empties into the right atrium. The anterior cardiac veins drain the front of the right ventricle and drain directly into the right atrium.[7]

The heart functions as a pump and acts as a double pump in the cardiovascular system to provide a continuous circulation of blood throughout the body. This circulation includes the systemic circulation and the pulmonary circulation. Both circuits transport blood but they can also be seen in terms of the gases they carry. The pulmonary circulation collects oxygen from the lungs and delivers carbon dioxide for exhalation.The systemic circuit transports oxygen to the body and returns relatively deoxygenated blood and carbon dioxide to the pulmonary circuit.[7]

Blood flows through the heart in one direction, from the atria to the ventricles, and out through the pulmonary artery into the pulmonary circulation, and the aorta into the systemic circulation. The pulmonary artery (also trunk) branches into the left and right pulmonary arteries to supply each lung. Blood is prevented from flowing backwards (regurgitation) by the tricuspid, bicuspid, aortic, and pulmonary valves.

The function of the right heart, is to collect de-oxygenated blood, in the right atrium, from the body (via the superior and inferior venae cavae and pump it, through the tricuspid valve, via the right ventricle, through the semilunar pulmonary valve and into the pulmonary artery in the pulmonary circulation where carbon dioxide can be exchanged for oxygen in the lungs.This happens through the passive process of diffusion. In the left heart oxygenated blood is returned to the left atrium via the pulmonary vein. It is then pumped into the left ventricle through the bicuspid valve and into the aorta for systemic circulation. Eventually in the systemic capillaries exchange with the tissue fluid and cells of the body occurs; oxygen and nutrients are supplied to the cells for their metabolism and exchanged for carbon dioxide and waste products[7] In this case, oxygen and nutrients exit the systemic capillaries to be used by the cells in their metabolic processes, and carbon dioxide and waste products will enter the blood.[7]

The ventricles are stronger and thicker than the atria, and the muscle wall surrounding the left ventricle is thicker than the wall surrounding the right ventricle due to the higher force needed to pump the blood through the systemic circulation. Atria facilitate circulation primarily by allowing uninterrupted venous flow to the heart, preventing the inertia of interrupted venous flow that would otherwise occur at each ventricular systole.[23]

Cardiac muscle tissue has autorhythmicity, the unique ability to initiate a cardiac action potential at a fixed rate - spreading the impulse rapidly from cell to cell to trigger the contraction of the entire heart. This autorhythmicity is still modulated by the endocrine and nervous systems.[7]

There are two types of cardiac muscle cell: cardiomyocytes which have the ability to contract easily, and modified cardiomyocytes the pacemaker cells of the conducting system. The cardiomyocytes make up the bulk (99%) of cells in the atria and ventricles. These contractile cells respond to impulses of action potential from the pacemaker cells and are responsible for the contractions that pump blood through the body. The pacemaker cells make up just (1% of cells) and form the conduction system of the heart. They are generally much smaller than the contractile cells and have few of the myofibrils or myofilaments which means that have limited contractibility. Their function is similar in many respects to neurons, though they are specialized muscle cells.[7]

Specialised cardiomyocytes known as Purkinje fibres function to conduct the action potentials with optimum efficiency. They are located in the subendocardium of the inner walls of the ventricles. Other specialised cardiomyocytes for giving efficient electrical conduction constitute the bundle of His.

Cardiomyocytes, are considerably shorter and have smaller diameters than skeletal myocytes. Cardiac muscle (like skeletal muscle) is characterized by striations - the stripes of dark and light bands resulting from the organised arrangement of myofilaments and myofibrils in the sarcomere along the length of the cell. T (transverse) tubules are deep invaginations from the sarcolemma (cell membrane) that penetrate the cell, allowing the electrical impulses to reach the interior. In cardiac muscle the T-tubules are only found at the Z-lines.[7] When an action potential causes cells to contract, calcium is released from the sarcoplasmic reticulum of the cells as well as the T tubules. The calcium release triggers sliding of the actin and myosin fibrils leading to contraction.[24] A plentiful supply of mitochondria provide the energy for the contractions. Typically, cardiomyocytes have a single, central nucleus, but can also have two or more.[7]

Cardiac muscle cells branch freely and are connected by junctions known as intercalated discs which help the synchronized contraction of the muscle.[25] The sarcolemma (membrane) from adjacent cells bind together at the intercalated discs. They consist of desmosomes, specialized linking proteoglycans, tight junctions, and large numbers of gap junctions that allow the passage of ions between the cells and help to synchronize the contraction. Intercellular connective tissue also helps to strongly bind the cells together, in order to withstand the forces of contraction.[7]

Cardiac muscle undergoes aerobic respiration patterns, primarily metabolizing lipids and carbohydrates. Myoglobin, lipids, and glycogen are all stored within the sarcoplasm. The cells undergo twitch-type contractions with long refractory periods followed by brief relaxation periods when the heart fills with blood for the next cycle.[7]

It is not very well known how the electric signal moves in the atria. It seems that it moves in a radial way, but Bachmann's bundle and coronary sinus muscle play a role in conduction between the two atria, which have a nearly simultaneous systole.[26][27][28] While in the ventricles, the signal is carried by specialized tissue called the Purkinje fibers which then transmit the electric charge to the myocardium.[29]

If embryonic heart cells are separated into a Petri dish and kept alive, each is capable of generating its own electrical impulse followed by contraction. When two independently beating embryonic cardiac muscle cells are placed together, the cell with the higher inherent rate sets the pace, and the impulse spreads from the faster to the slower cell to trigger a contraction. As more cells are joined together, the fastest cell continues to assume control of the rate. A fully developed adult heart maintains the capability of generating its own electrical impulse, triggered by the fastest cells, as part of the cardiac conduction system. The components of the cardiac conduction system include the atrial and ventricular syncytium, the sinoatrial node, the atrioventricular node, the bundle of His (atrioventricular bundle), the bundle branches, and the Purkinje cells.[7]

Normal sinus rhythm is established by the sinoatrial (SA) node, the heart's pacemaker. The SA node is a specialized grouping of cardiomyocytes in the upper and back walls of the right atrium very close to the opening of the superior vena cava. The SA node has the highest rate of depolarization.[7]

This impulse spreads from its initiation in the SA node throughout the atria through specialized internodal pathways, to the atrial myocardial contractile cells and the atrioventricular node. The internodal pathways consist of three bands (anterior,middle, and posterior) that lead directly from the SA node to the next node in the conduction system, the atrioventricular node. The impulse takes approximately 50 ms (milliseconds) to travel between these two nodes. The relative importance of this pathway has been debated since the impulse would reach the atrioventricular node simply following the cell-by-cell pathway through the contractile cells of the myocardium in the atria. In addition, there is a specialized pathway called Bachmann’s bundle or the interatrial band that conducts the impulse directly from the right atrium to the left atrium. Regardless of the pathway, as the impulse reaches the atrioventricular septum, the connective tissue of the cardiac skeleton prevents the impulse from spreading into the myocardial cells in the ventricles except at the atrioventricular node.[7]The electrical event, the wave of depolarization, is the trigger for muscular contraction. The wave of depolarization begins in the right atrium, and the impulse spreads across the superior portions of both atria and then down through the contractile cells. The contractile cells then begin contraction from the superior to the inferior portions of the atria, efficiently pumping blood into the ventricles.[7]

The atrioventricular (AV) node is a second cluster of specialized myocardial conductive cells, located in the inferior portion of the right atrium within the atrioventricular septum. The septum prevents the impulse from spreading directly to the ventricles without passing through the AV node. There is a critical pause before the AV node depolarizes and transmits the impulse to the atrioventricular bundle. This delay in transmission is partially attributable to the small diameter of the cells of the node, which slow the impulse. Also, conduction between nodal cells is less efficient than between conducting cells. These factors mean that it takes the impulse approximately 100 ms to pass through the node. This pause is critical to heart function, as it allows the atrial cardiomyocytes to complete their contraction that pumps blood into the ventricles before the impulse is transmitted to the cells of the ventricle itself. With extreme stimulation by the SA node, the AV node can transmit impulses maximally at 220 per minute. This establishes the typical maximum heart rate in a healthy young individual. Damaged hearts or those stimulated by drugs can contract at higher rates, but at these rates, the heart can no longer effectively pump blood.[7]

Bundle of His, bundle branches, and Purkinje fibers

Arising from the AV node, the bundle of His, proceeds through the interventricular septum before dividing into two bundle branches, commonly called the left and right bundle branches. The left bundle branch has two fascicles. The left bundle branch supplies the left ventricle, and the right bundle branch the right ventricle. Since the left ventricle is much larger than the right, the left bundle branch is also considerably larger than the right. Portions of the right bundle branch are found in the moderator band and supply the right papillary muscles. Because of this connection, each papillary muscle receives the impulse at approximately the same time, so they begin to contract simultaneously just prior to the remainder of the myocardial contractile cells of the ventricles. This is believed to allow tension to develop on the chordae tendineae prior to right ventricular contraction. There is no corresponding moderator band on the left. Both bundle branches descend and reach the apex of the heart where they connect with the Purkinje fibers. This passage takes approximately 25 ms.[7]

The Purkinje fibers are additional myocardial conductive fibers that spread the impulse to the myocardial contractile cells in the ventricles. They extend throughout the myocardium from the apex of the heart toward the atrioventricular septum and the base of the heart. The Purkinje fibers have a fast inherent conduction rate, and the electrical impulse reaches all of the ventricular muscle cells in about 75 ms. Since the electrical stimulus begins at the apex, the contraction also begins at the apex and travels toward the base of the heart, similar to squeezing a tube of toothpaste from the bottom. This allows the blood to be pumped out of the ventricles and into the aorta and pulmonary trunk. The total time elapsed from the initiation of the impulse in the SA node until depolarization of the ventricles is approximately 225 ms.[7]

Membrane potentials and ion movement in cardiac conductive cells

Action potentials are considerably different between conductive and contractive cardiomyocytes. While sodium Na+ and potassium K+ ions play essential roles, calcium ions Ca2+ are also critical for both types of cell. Unlike skeletal muscles and neurons, cardiac conductive cells do not have a stable resting potential. Conductive cells contain a series of sodium ion channels that allow a normal and slow influx of sodium ions that causes the membrane potential to rise slowly from an initial value of −60 mV up to about –40 mV. The resulting movement of sodium ions creates spontaneous depolarization (or prepotential depolarization).[7]

At this point, calcium channels open and Ca2+ enters the cell, further depolarizing it at a more rapid rate until it reaches a value of approximately +5 mV. At this point, the calcium ion channels close and potassium channels open, allowing outflux of K+ and resulting in repolarization. When the membrane potential reaches approximately −60 mV, the K+ channels close and Na+ channels open, and the prepotential phase begins again. This process gives the autorhythmicity to cardiac muscle.[7]

Membrane Potentials and ion movement in cardiac contractile cells

There is a distinctly different electrical pattern involving the contractile cells. In this case, there is a rapid depolarization, followed by a plateau phase and then repolarization. This phenomenon accounts for the long refractory periods required for the cardiac muscle cells to pump blood effectively before they are capable of firing for a second time. These cardiac myocytes normally do not initiate their own electrical potential, although they are capable of doing so, but rather wait for an impulse to reach them.[7]

Contractile cells demonstrate a much more stable resting phase than conductive cells at approximately −80 mV for cells in the atria and −90 mV for cells in the ventricles. Despite this initial difference, the other components of their action potentials are virtually identical. In both cases, when stimulated by an action potential, voltage-gated channels rapidlyopen, beginning the positive-feedback mechanism of depolarization. This rapid influx of positively charged ions raises the membrane potential to approximately +30 mV, at which point the sodium channels close. The rapid depolarization period typically lasts 3–5 ms. Depolarization is followed by the plateau phase, in which membrane potential declines relatively slowly. This is due in large part to the opening of the slow Ca2+ channels, allowing Ca2+ to enter the cell while few K+ channels are open, allowing K+ to exit the cell. The relatively long plateau phase lasts approximately 175 ms. Once the membrane potential reaches approximately zero, the Ca2+ channels close and K+ channels open, allowing K+ to exit the cell. The repolarization lasts approximately 75 ms. At this point, membrane potential drops until it reaches resting levels once more and the cycle repeats. The entire event lasts between 250 and 300 ms.[7]

The absolute refractory period for cardiac contractile muscle lasts approximately 200 ms, and the relative refractory period lasts approximately 50 ms, for a total of 250 ms. This extended period is critical, since the heart muscle must contract to pump blood effectively and the contraction must follow the electrical events. Without extended refractory periods, premature contractions would occur in the heart and would not be compatible with life.[7]

Calcium ions

Calcium ions play two critical roles in the physiology of cardiac muscle. Their influx through slow calcium channels accounts for the prolonged plateau phase and absolute refractory period. Calcium ions also combine with the regulatory protein troponin in the troponin complex. Both roles enabling the myocardium to function properly.[7]

Approximately 20 percent of the calcium required for contraction is supplied by the influx of Ca2+ during the plateau phase. The remaining Ca2+ for contraction is released from storage in the sarcoplasmic reticulum.[7]

Comparative rates of conduction system firing

The pattern of prepotential or spontaneous depolarization, followed by rapid depolarization and repolarization just described, are seen in the SA node and a few other conductive cells in the heart. Since the SA node is the pacemaker, it reaches threshold faster than any other component of the conduction system. It will initiate the impulses spreading to the other conducting cells. The SA node, without nervous or endocrine control, would initiate a heart impulse approximately 80–100 times per minute. Although each component of the conduction system is capable of generating its own impulse, the rate progressively slows from the SA node to the Purkinje fibers. Without the SA node, the AV node would generate a heart rate of 40–60 beats per minute. If the AV node were blocked, the atrioventricular bundle would fire at a rate of approximately 30–40 impulses per minute. The bundle branches would have an inherent rate of 20–30 impulses per minute, and the Purkinje fibers would fire at 15–20 impulses per minute. While a few exceptionally trained aerobic athletes demonstrate resting heart rates in the range of 30–40 beats per minute (the lowest recorded figure is 28 beats per minute for Miguel Indurain, a cyclist)–for most individuals, rates lower than 50 beats per minute would indicate a condition called bradycardia. Depending upon the specific individual, as rates fall much below this level, the heart would be unable to maintain adequate flow of blood to vital tissues, initially resulting in decreasing loss of function across the systems, unconsciousness, and ultimately death.[7]

The period of time that begins with contraction of the atria and ends with ventricular relaxation is known as the cardiac cycle. The period of contraction that the heart undergoes while it pumps blood into circulation is called systole. The period of relaxation that occurs as the chambers fill with blood is called diastole. Both the atria and ventricles undergo systole and diastole, and it is essential that these components be carefully regulated and coordinated to ensure blood is pumped efficiently to the body.[7]

Fluids, move from regions of high pressure to regions of lower pressure. Accordingly, when the heart chambers are relaxed (diastole), blood will flow into the atria from the higher pressure of the veins. As blood flows into the atria, the pressure will rise, so the blood will initially move passively from the atria into the ventricles. When the action potential triggers the muscles in the atria to contract (atrial systole), the pressure within the atria rises further, pumping blood into the ventricles. During ventricular systole, pressure rises in the ventricles, pumping blood into the pulmonary trunk from the right ventricle and into the aorta from the left ventricle.[7]

At the beginning of the cardiac cycle, both the atria and ventricles are relaxed (diastole). Blood is flowing into the right atrium from the superior and inferior venae cavae and the coronary sinus. Blood flows into the left atrium from the four pulmonary veins. The two atrioventricular valves, the tricuspid and mitral valves, are both open, so blood flows unimpeded from the atria and into the ventricles. Approximately 70–80 percent of ventricular filling occurs by this method. The two semilunar valves, the pulmonary and aortic valves, are closed, preventing backflow of blood into the right and left ventricles from the pulmonary trunk on the right and the aorta on the left.

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