ELECTROPHYSIOLOGY

CARDIOVASCULAR
Tujuan
 Mengetahui sel didalam jantung
 Aliran listrik yang terdapat di jantung
 Ion chanel yang berbeda di jantung
 Bagaimana potensial aksi yang terdapat di jantung
Anatomi Jantung
ANATOMI & FISIOLOGI
JANTUNG
ANATOMI & FISIOLOGI
JANTUNG
• Otot jantung termasuk otot
bergaris
• Mempunyai miofibril
• Otot jantung saling berhubungan
satu sama lain /sinsisium
• Sifat sinsisium apabila satu sel otot
jantung terangsang, potensial aksi
akan menyebar dari satu sel ke sel
lain
Sinsisium
1. Hukum all or none berlaku, artinya bila atrium
atau ventrikel sudah eksitasi, selalu diikuti oleh
kontraksi seluruh jantung
2. Sifat dasar otot jantung :
a. irritability (bathmotropic) = peka rangrang
b. conductivity (dromotropic) = hantar rangsang
c. contractility (inotropic) = dapat berkontraksi
d. rhythmicity ( chronotropic) = bersifat ritmis
Figure 14-17
-Miofibril pada otot jantung mengandung
filamen aktin (filamen tebal) dan miosin
(filamen tipis terdiri atas 3 protein aktin,
tropomiosin dan troponin)
KERJA OTOT JANTUNG
Some definitions
 Preload: the initial stretching of the cardiac myocytes
prior to contraction.
 End diastolic volume: the volume of blood in a
ventricle at the end of filling

 Determining factor:
 Venous return

Preload Pumps up the heart.

Some definitions
 Afterload: the force the sarcomere
must overcome in order to shorten
during systole
 Determining factor:
 Aortic pressure
Sistem konduksi listrik
 Sinoatrial Node (Sinus Node or SA Node)
 “Normal pacemaker”
 Internodal Atrial Pathways
 Atrioventricular Junction (AV junction)
 AV node
 “Gatekeeper”

 slows conduction to the ventricles allowing time for

ventricles to fill
 Bundle of His
 Sistem konduksi listrik
 His-Purkinje System
 Bundle Branches
 Right bundle branch

 Left bundle branch

 left anterior fascicle
 left posterior fascicle
Electrophysiology
 Elektrolit
 Yang berfungsi dijantung
 Sodium: major extracellular cation, berperan sebagai
depolarisasi
 Potassium: major intracellular cation, berperan sebagai
repolarisasi
 Calcium: intracellular cation, berperan sebagai depolarisasi
dan kontraksi otot jantung
 Chloride: extracellular anion

 Magnesium: intracellular cation

 Kandungan elektrolit dalam sel
Table 1. Transcellular electrolyte gradients

ECS ICS

Potassium 4 .5 150 mM
Magnesium 1 3 mM
Sodium 145 11 mM
Calcium 2 .5 0 .0001 mM
The balance of electrostatic and concentration forces for each ion
in the cell are described by the Nernst equation

Ek = -61.5mv log ( [ion inside] / [ion outside] )

Where Ek = membrane charge (potential) for a given ion
• Elektrolit homeostatis = elektrolit luar dan dalam sel sama
Transportasi elektrolit di jantung melalui :

1.Difusi

2. Transportasi
 Transportasi elektrolit di jantung
• Resting membran potensial otot jantung – 90 mV

Kurva potensial aksi dibagi atas 4

phase :
Phase 4 : Membran resting
Phase 0 : Depolarisasi, peningkatan
masuk Na+ secara tajam
Phase 1 : Repolarisasi, terbuka
saluran K+
Phase 2 : Peningkatan masuk Ca2+
mengimbangi keluar K+
Phase 3 : Repolarisasi, masuknya
K+ dan keluar Ca2+
Electrophysiology
Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+

K+ K+ K+

K+ K+

Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+

Myocardial cells are POLARIZED. They have more positive charges outside
than inside.
Electrophysiology
Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+

K+ K+ K+ K+ K+

Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+

Stimulation of cell opens “fast” channels in cell membrane. Na+ rapidly

enters cell. Now there are more positive charges inside than outside. The
cell is DEPOLARIZED.
Electrophysiology
 Depolarisasi disebabkan pelepasan Ca2+ kedalam sel.
 Pelepasan Ca2+ menimbulkan kontraksi
Electrophysiology
Na+ Na+ Na+ Na+ K+ Na+ Na+ Na+ Na+

Na+

K+ K+

Na+ Na+

K+ Na+ Na+ Na+ Na+ Na+ K+ Na+ Na+

Cell then REPOLARIZES by pumping out K+ then Na+ to restore normal

charge balance.
Electrophysiology
Na+ Na+ Na+ Na+ K+ Na+ Na+ Na+ Na+

Na+

K+ K+
Na+ Na+

K+ Na+ Na+ Na+ Na+ Na+ K+ Na+ Na+

Finally, the Na+-K+ pump in the cell membrane restores the proper balance
of sodium and potassiuim.
 Cardiac Conduction Cycle

Phase 0 = rapid Na influx

Phase 1 = stop Na influx, K efflux, Cl influx
Phase 2 = Ca influx, K influx Sarcomere:
Phase 3 = stop Ca influx, minimal K efflux, Na efflux Fast Sodium
Phase 4 = resting membrane potential state Channels
CARDIAC CYCLE
opens

Mitral
Aortic

Closes

Atrial Systole
Isovolumic contract.

S1
Rapid Ejection

Reduced Ejection

S2
Isovolumic Relax.
Rapid Ventricular
Filling

Reduced Ventricular
Filling

Atrial Systole
opens
closes
Mitral
Aortic
Flow of Cardiac Electrical Activity
(Potensial aksi)
SA node Pacing (sets heart rate)

Atrial Muscle Contraction

AV node Delay

Purkinje System Rapid, uniform spread

Ventricular Contraction
Muscle
Electrophysiology
 Pacemaker Sites of the Heart & Intrinsic Firing
Rates
 Specialized groups of cells called pacemaker sites

 SA Node 60 to 100 bpm

 AV Junction 40 to 60 bpm

 Ventricles 20 to 40 bpm
 Electrophysiology Ca2+

Ca2+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+

K+ K+ K+

K+ K+

Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+

Ca2+
Ca2+

Specialized cells in conducting system (pacemaker cells) undergo

spontaneous diastolic depolarization. During diastole, calcium leaks into
cell through calcium channels.
Electrophysiology
Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+

K+ K+ K+ K+ K+

Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+

When a critical amount of calcium has entered the cell, fast channels
open, sodium enters, and rapid DEPOLARIZATION begins.
 Electrophysiology
 Electrical impulse
from depolarizing
pacemaker cell
spreads to working
myocardial cells and
stimulates them.

Depolarization and
contraction result.
Pacemaker (If) Channel (HCN4)
 Activated by negative potential
 Not particularly selective: allows both Na and K
 SA Node Action Potential
Voltage-gated Ca+2 channels
SA node membrane potential (mV)

0 Voltage-gated K+ channels

No inward-rectifier
-50
K+ channels

If or pacemaker
200 msec channels
 AV Node Action Potentials
l Similar to SA node
AV node membrane potential (mV)

l Latent pacemaker
0 l Slow, Ca+2-
dependent upstroke
SA node l Slow conduction
-50 (delay)
l K+-dependent
AV node
200 msec repolarization
 Calcium channel blockers

Used for:
Angina
Hypertension
Arrhythmias

Dihydropyridine class and Verapamil

Decrease entry of calcium and delay the depolarization of SA and AV nodal cells.
Antiarrhythmic Drugs
 Class I: Local anesthetic action, reducing Na
channel current
 Quinidine
 Lidocaine
 Class III: action potential prolongation- usually by
inhibiting cardiac K channels
 Amiodarone
 Class IV - Ca channel antagonists
 Verapamil
 Potassium channel blockers

-Slow repolarization and therefore extends the Effective Refractory Period.

-Extends the “Q-T interval” on the electrocardiogram (lecture Part II)
-Helpful in preventing tachyarrhythmias from re-entry mechanisms (lecture Part II).
 Sodium channel blockers

-Slow the rate and magnitude of depolarization in non-nodal cells

-Used to treat tachycardia
-Extends the Effective Refractory Period
Beta blockers

-Prevent calcium entry into the cell

-Decrease HR, conduction velocity, strength
of contraction.

-Used to treat many CVS conditions:

-Hypertension (inhibit renin)

-Angina/myocardial infarction
-Arrhythmias (slows rate of depol.)
Changes in contractility
 Digoxin:
 inhibits Na-K ATPase Ejection fraction
is an indicator of
 Ca++ builds up contractility
EF= SV/EDV
 The Electrocardiogram

P wave – depolarisasi atrium

QRS complex – depolarisasi ventrikel
T wave – repolarization ventrikel
*repolarization of atria lies under QRS

What information does the EKG give you?

rate, rhythm, tissue health
 From Table 20-3

Electrical Properties of Different Cardiac Tissues

Tissue Name Function Major B-adrenergic Cholinergic
Currents Effects Effects

SA Node Primary Ica, Ik, If ↑ conduction ↓ conduction

Pacemaker velocity and velocity and
pacemaker rate pacemaker rate
AV node Secondary Ica, Ik, If ↑ conduction ↓ conduction
Pacemaker velocity and velocity and
pacemaker rate pacemaker rate
Purkinje Tertiary Ica, Ik, If, Ina ↑ pacemaker ↓ pacemaker
fibers Pacemaker rate rate
Rapid conduction of
AP
Atrial Muscle Expel blood from Ica, Ik, Ina ↑ strength of Little effect
Atria contraction

Ventricular Expel blood from Ica, Ik, Ina ↑ strength of Little effect
Muscle Ventricles contraction
 Two cell model of EKG activity

Positive isoelectric
deflection
Negative
deflection

When wave of depolarization moves towards a

positive electrode, the deflection is positive.

Fig. 20-9
12 Lead EKG
6 limb leads – define
electrical activity in
frontal plane

6 precordial leads –
define electrical activity
in transverse plane

Each lead is a single axis

in one of the planes

The 3 augmented leads compare

one limb electrode to the
average of the other two.
(aVR, aVL, aVF)

Leads are made of a combination of

electrodes that form imaginary lines
in the body along which the electrical
signals are measured.

Fig. 20-7
 Einthoven’s Triangle
(6 limb leads)

Electrical axis of the heart is normally between -30 and 90 degrees.

Fig. 20-8
 Willem Einthoven
Nobel prize in 1924 for electrocardiogram
(discovered in 1903)
Atrial Depolarization and the Inscription of the P-wave
Vetricular Depolarization and the Inscription of the QRS complex
Ventricular Repolarization and the Inscription of the T-wave
The QRS Complex with Interval and Segment Measurements
ECG Paper and related Heart Rate & Voltage Computations
 The Concept of a “Lead”

Lead I

• Right arm (RA) negative, left

arm (LA) positive, right leg (RL) - +
ground……this arrangement of
electrodes enables a "directional
view" recording of the heart's
electrical potentials as they are
sequentially activated
throughout the entire cardiac
cycle G
Electrocardiograph
 The Concept of a “Lead”

Lead I

- +
• The directional flow of electricity from
Lead I can be viewed as flowing from the
RA toward the LA and passing through
the heart. Also, it is useful to imagine a
camera lens taking an "electrical picture"
of the heart with the lead as its line of
sight
 The Concept of a “Lead”

LA
Leads I, II, and III
RA
- -

• By changing the
RA - + LA
arrangement of which LEAD I
arms or legs are
positive or negative,
two other leads ( II &
LEAD III +LL
III ) can be created and LL
+
we have two more LEAD II
"pictures" of the
heart's electrical
activity from different
angles
Remember, the RL
is always the ground
 The Concept of a “Lead”

RA & LA
Augmented Voltage leads -
AVR, AVL, and AVF
LEAD AVR LEAD AVL
RA +
• By combining certain + LA
limb leads into a central
terminal, which served
as the negative
electrode, other leads
could be formed to "fill
in the gaps" in terms of - -
the angles of directional RA & RL LL & LA
recording. These leads
required augmentation LL +
of voltage to be read and LEAD AVF
are thus labeled.
 The Concept of a “Lead”

Summary of the LEAD AVR

“Limb Leads” LEAD AVL
-150o -30o

• Each of the limb

leads (I, II, III, AVR, 0o
AVL, AVF) can be LEAD I
assigned an angle of
clockwise or
counterclockwise 60o
rotation to describe 120o LEAD II
its position in the 90o
LEAD III
frontal plane LEAD AVF
 The Concept of a “Lead”

The “Precordial Leads”

4th
intercostal
• Each of the space V1 V2
V3
precordial leads is V4 V5 V6
unipolar
(1 electrode
constitutes a lead)
and is designed to
view the electrical
activity of the • V1 - 4th intercostal space - right margin of sternum
heart in the • V2 - 4th intercostal space - left margin of sternum
horizontal or • V3 - linear midpoint between V2 and V4
transverse plane • V4 - 5th intercostal space at the mid clavicular line
• V5 - horizontally adjacent to V4 at anterior axillary line
• V6 - horizontally adjacent to V5 at mid-axillary line
 Hexaxial Array for Axis Determination

determination of the
angle of the
main cardiac vector
in the frontal plain
 Hexaxial Array for Axis Determination – Example 1

Lead I

If lead I is mostly
positive, the
axis must lie in the
right half of
of the coordinate
system (the main
vector is moving
mostly toward the
lead’s positive
electrode)
 Hexaxial Array for Axis Determination – Example 1

Lead AVF

If lead AVF is
mostly positive, the
axis must lie in the
bottom half of
of the coordinate
system (again, the
main vector is
moving mostly
toward the lead’s
positive electrode
 Hexaxial Array for Axis Determination – Example 1

I AVF

Combining the two

plots, we see
that the axis must
lie in the bottom
right hand quadrant
 Hexaxial Array for Axis Determination – Example 1
I AVF AVL

Once the quadrant has

been determined, find
the most equiphasic or
smallest limb lead. The
axis will lie about 90o
away from this lead.
Given that AVL is the
most equiphasic lead, the
axis here is at
approximately 60o.
 Hexaxial Array for Axis Determination – Example 1
I AVF AVL

Since QRS complex in

AVL is a slightly more
positive, the true axis
will lie a little closer to
AVL (the depolarization
vector is moving a little
more towards AVL than
away from it). A better
estimate would be about
50o (normal axis).
 Hexaxial Array for Axis Determination – Example 2

Lead I

If lead I is mostly
negative, the
axis must lie in
the left half of
of the coordinate
system.
 Hexaxial Array for Axis Determination – Example 2

Lead AVF

If lead AVF is mostly

positive, the
axis must lie in the
bottom half of
of the coordinate
system
 Hexaxial Array for Axis Determination – Example 2

I AVF

Combining the two

plots, we see
that the axis must
lie in the bottom
left hand quadrant
(Right Axis
Deviation)
 Hexaxial Array for Axis Determination – Example 2

I AVF II

Once the quadrant

has been determined,
find the most
equiphasic or
smallest limb lead.
The axis will lie about
90o away from this
lead. Given that II is
the most equiphasic
lead, the axis here is
at approximately 150o.
 Hexaxial Array for Axis Determination – Example 2

I AVF II

Since the QRS in II is

a slightly more
negative, the true axis
will lie a little farther
away from lead II
than just 90o (the
depolarization vector
is moving a little
more away from lead
II than toward it). A
better estimate would
be 160o.
Precise Axis
Calculation
Precise calculation
of the axis can be
done using the
coordinate system
to plot net voltages
of perpendicular
leads, drawing a Net voltage = 12
resultant rectangle, Since Lead III is
then connecting the the most

Net voltage = 7
origin of the equiphasic lead
coordinate system and it is slightly
with the opposite more positive than
corner of the negative, this axis
rectangle. A could be
protractor can then estimated at about
be used to measure 40o.
the deflection from
0.
 What does the axis tell us?

Left axis deviation

(between -90 and -30 degrees)
-Short and/or obese persons
-parallels amount of conductance over tissue

Right axis deviation

(between 180 and 90 degrees)
-Tall and thin persons
-parallels amount of conductance over tissue
Conduction Blocks
 First degree AV block
 Slowing of conduction from SA to AV
 Longer P-R intervals
 Second degree AV block
 Partial block/intermittent
 P wave intermittently dissociated from QRS (Mobitz type I and II)
(long P-R or absent QRS)
 Third degree AV block
 Complete block of impulse – complete AV dissociation.
 Atria and Ventricles are electrically separate, Purkinje take over
 P waves and QRS have no relationship
 Usually requires artificial pacemaker
 Conduction Arrhythmias

Normal First degree block

Second degree block

Third degree block

WPW
 Wolff-Parkinson-White Syndrome

-Common example of accessory conduction

pathway (Bundle of Kent)

-A common route for a re-entry pathway

-Often results in supraventricular tachycardia
-Occurs in ~ 0.3-1% of population

Delta wave

(Bundle of Kent)
 HYPOKALEMIA

- decreases amplitude or inversion of the T wave

- increases amplitude of the U wave
- prolongation of the Q-T interval
- Increased amplitude of the P wave, prolongation of the P-R interval
- Widening of the QRS complex
 UNI AND BIDIRECTIONAL BLOCK
CLINICAL IMPLICATIONS
B
A
ANTEGRADE
NORMAL BLOCK

C D
REENTRY
UNIDIRECTIONAL
BI
BLOCK
 Clinical Correlation
Re-entry Tachycardias
Paroxysmal Supraventricular Tachycardia
Ischemic Tissue

Slow Fast Fast

Slow
Pathway Pathway Pathway
Pathway

Normal Conduction Re-Entry Circuit

CONDUCTION IN THE VENTRICLES
 PURKINJE FIBERS WITH LONG REFRACTORY
PERIODS.
 PROTECTION AGAINST PREMATURE ATRIAL
DEPOLARIZATIONS AT SLOW HEART RATES.
 AV NODE PROTECS AT HIGH HEART RATES.