Upload
deep-chandh
View
580
Download
5
Tags:
Embed Size (px)
Citation preview
Myocardial Action Potentialand
Mechanisms of ArrythmogenesisBasic Concepts & Clinical Implications
Dr. S.Deep Chandh Raja
SYNOPSIS
• Anatomy of the Conduction System
• Ion channels and Clinical Implications
• Myocardial Action Potential
• Basis of Arrythmogenesis
• ECG examples of Arrythmias
• Concept of Entrainment
Anatomy of the Conduction System
SA Node
SA NODE
• Spindle shaped, 10-20 mm, jxn. Of SVC and Right Atrium in the sulcus terminalis
• 60% RCA,
• Spindle and spider cells possess pacemaker characteristics
• Β1, B2, M2 receptors
• Neurotransmitters- Neuropeptide Y, VIP
• Postvagal Tachycardia
Internodal Tracts• Theory questioned
• Transitional tissue of Atrium muscle
AV NODE
• Inferior nodal extension, Compact Portion, Penetrating bundle
• Koch’s triangle
• AV nodal artery from crux of RCA (90%)
• Slow propagation velocity
Bundle of HIS
• Continuation of the penetrating bundle of AV node
• Located in the upper portion of IVS
• Dual blood supply
• Resistant to ishemia
CONDUCTION AV NODE HIS BUNDLE
ATROPINE IMPROVES WORSENS
Bundle branches
• Right BB continuation of HIS bundle
• LBB has 2-3 fascicles which are not exactly bundles, variable anatomy
• LP fascicle resistant to ischemia, dual blood supply
Purkinje Fibres
• Interweaving networks of fibres on the endocardial surface penetrating 1/3 rd of endocardium
• Concentrated more at apex and less at base and papillary muscle tips
• Large surface area and resistant to ischemia
What are false tendons?
Heart Rhythm, Volume 11, Issue 2, Pages 321–324, February 2014
“ Successful ablation of a narrow complex tachycardia arising from a left ventricular false tendon: Mapping and optimizing energy delivery”
Tissues susceptible to ischemia
• SA node
• AV node
• Bundle branches
• HIS bundle, Purkinje fibres resistant to ischemia
Electrophysiological Properties
Few important concepts on Nervous distribution
• Sidedness- Right stellate ganglion and vagal nerves affect the SA node more,
• The left sympathetic and vagal nerves affect the AV node more
• Tonic vagal stimulation causes greater absolute reduction in SA rate in presence of tonic background sympathetic stimulation—ACCENTUATED ANTAGONISM
• Differential distribution of Sympathetic and parasympathetic nerves- sympathetic more at base, PS more in the inferior myocardium (responsible for vagomimetic effects of Inferior MI)
SYNOPSIS
• Anatomy of the Conduction System
• Ion channels and Clinical Implications
• Myocardial Action Potential
• Basis of Arrythmogenesis
• ECG examples of Arrythmias
• Concept of Entrainment
Ion channels
Ion Channels
• Named after the Ion like Na, K, Ca or the NT affecting the channel like Ik.ach, Ik.atp
• Gating of channels
• Voltage dependence (RMP of the membrane its situated on)
• Time dependence
Salient features and clinical correlation
Na+ Channel• Nav 1.5 is an alpha subunit coded by SCN5A
gene
• LQT3 –disrupted inactivationprolonged APD
• SIDS-diminished inactivation
• Brugada syndrome- reduced activity
Ca2+ channels
• L Ca2+
• T Ca2+ channel
K+ channelMUTATIONS IN:
LQT1 KCNQ1 unit of K channel
LQT2 KCNH2
LQT5 KCNE1
Inward Rectifying K+ channels
• I k.ATP ischemic preconditioning, nicorandiland diazoxide open these channels, glibenclamide inhibit
• I k.ACH decreases spontaneous depolarisation in SA node and slows AV conduction, ADENOSINE increases activity
CARDIAC PACEMAKER CHANNEL
• Pacemaker current Funny current “If”
• Encoded by HCN4 gene
• Mutation familial sinus bradycardia
CONNEXINS
• Proteins forming the gap junctions which are responsible for anisotropy in heart
• Connexin 43 abundant in human cardiac myocardium
MUTATIONS IN:
Carvajal syndrome Desmoplakin
Naxos Disease Plakoglobin
ARVD Plakophilin2
Clinical implications of knowing about Ion channels
Summary of Ion Channels
SYNOPSIS
• Anatomy of the Conduction System
• Ion channels and Clinical Implications
• Myocardial Action Potential
• Basis of Arrythmogenesis
• ECG examples of Arrythmias
• Concept of Entrainment
SA NODE AUTOMATICITY
• CALCIUM CLOCKMEMBRANE CLOCK
Heart RhythmVolume 11, Issue 7, Pages 1210–19, July 2014
“Synchronization of sinoatrial node pacemaker cell clocks and its autonomic modulation impart complexity to heart beating intervals”
RESTING MEMBRANE POTENTIAL
• The RMP of a cell is the same as the Nernst potential of the predominant active ion channels in the cell
• For Cardiac cells, that which determines the RMP are the POTASSIUM CHANNELS
• Hence the RMP of a resting cell approximates – 90 mv (The Nernst potential of K+ channel)
Action Potential
• Deviation from RMP as a result of influx and efflux of ions, leading to increase in positive charges (Depolarisation) and decrease in positive charges (Repolarisation)
Action potential of the cardiac muscles
• The cardiac action potential is made
of 3 phases:
1. Depolarization:
2. Plateau:
3. Replarization:
MAP OF NODE VS MYOCARDIUM
• SA NODE
• AV NODE
• DISEASE MYOCARDIUM
• ATRIAL MUSCLE
• VENTRICULAR MUSCLE
• PURKINJE FIBRE
Electrophysiological Properties
MAP OF MYOCARDIUM
• PHASE 4- THE RMP
• PHASE 0- RAPID UPSTROKE
• PHASE 1- INITIAL DOWNSTROKE
• PHASE 2- PLATEAU
• PHASE 3- FINAL DOWNSTROKE
PHASE 4
• 3 MAIN CHANNELS
o Inward rectifying potassium channels-
Potassium efflux helps maintain negativity
o Na-Ca exchanger
o Na-K ATPase
PHASE 0
• 2 inward currents
• SUDDEN INCREASE IN MEMBRANE INFLUX OF Na+
• Stimulus should be enough to take the MP past the threshold, beyond which “the size of AP is independent of the strength of the stimulus- ALL OR NONE RESPONSE”
• Later part of upstroke is contributed by Slow Inward Ca channel opening
• Initial curve- FAST RESPONSE Na channels
Time dependent inactivation, usually close at around + 60 mv
• Later curve- SLOW RESPONSE L-Ca channels
Activated at around -30 mv, continue into the plateau phase
Class 1A inhibit
Class IV inhibit
Phase 1-Early rapid repolarisation
• Inactivation of inward Na current
• Activation of 3 main outward currents leading to efflux of positive charges
o K+
o Cl-
o Na/Ca exchanger
• Typical notch
Phase 1 notch
Phase 2-Plateau phase
• Competition between the outward and inward currents lead to Plateau phase
• Steady state phase
Phase 3-Final rapid repolarisation
• Time dependent inactivation of Inward L-Ca current
• Activation of a number of K+ channels-Ikr, Iks, Ik.ach, Ik.ca-leading to outward K+ current and loss of positivity return to a more negative steady state (the RMP)
K+ channels-Ikr, Iks, Ik.ach, Ik.ca
Prolongation of plateau phase
Prolongation of action potential
LONG QT
HERG mutation
ErythromycinKetoconazole
MAP OF SA & AV NODE
• PHASE 4- SLOW DIASTOLIC DEPOLARISATION
“PACEMAKER POTENTIAL”
• PHASE 0- SLOW UPSTROKE
• PHASE 3- DOWNSTROKE
PHASE 4 “PACEMAKER POTENTIAL”
• SLOW DIASTOLIC DEPOLARISATION- “no REST for SA node, AV node”
• Maintained by Funny currents “If”
• Hyperpolarisation current activated by Na and K+, Transient Ca2+ channels
• Influenced by adrenergic and cholinergic neurotransmitters
How does the SA node fasten its rate?
PHASE 0
• SLOW UPSTROKE
• Due to Slow channel
• Upstroke contributed mainly by the inward slow L-Ca current rather than the fast Na current
PHASE 3
• K+ channel opening-outward movement of positive charges
• Other phases are the same
SUMMARY OF AP
POST REPOLARISATION REFRACTORINESS
• Even after the restoration of RMP in a cell, it continues to remain in a state of refractoriness to stimuli and hence non excitable
• This period is called
POST REPOLARISATION REFRACTORINESS, which is a time dependent phenomenon
Classification of Antiarrhythmic Drugs based on Drug Action
CLASS ACTION DRUGS
I. Sodium Channel Blockers
1A. Moderate phase 0 depression and
slowed conduction (2+); prolong
repolarization
Quinidine,
Procainamide,
Disopyramide
1B. Minimal phase 0 depression and slow
conduction (0-1+); shorten
repolarizationLidocaine
1C. Marked phase 0 depression and slow
conduction (4+); little effect on
repolarizationFlecainide
II. Beta-Adrenergic Blockers Propranolol, esmolol
III. K+ Channel Blockers
(prolong repolarization)
Amiodarone, Sotalol,
Ibutilide
IV. Calcium Channel Blockade Verapamil, Diltiazem
Classification of Anti-Arrhythmic Drugs
Heart RhythmVolume 11, Issue 3, Page e1, March 2014
“Propranolol, a β-adrenoreceptor blocker, prevents arrhythmias also by its sodium channel blocking effect”
SYNOPSIS
• Anatomy of the Conduction System
• Ion channels and Clinical Implications
• Myocardial Action Potential
• Basis of Arrythmogenesis
• ECG examples of Arrythmias
• Concept of Entrainment
MECHANISM OF ARRYTHMOGENESIS-Genetic basis
-Role of ANS-Proposed mechanisms
Key elements contributing to the development of acquired arrhythmias
Genetic basis of Arrythmias
ROLE OF ANS
• Alterations in vagal and sympathetic innervation and sensitivites to the same,
can lead to heterogeneity within the myocardium and hence serve a substrate to various arrthymias
• AUTONOMIC REMODELLING
ROLE OF ANS
• Alterations in vagal and sympathetic innervation and sensitivites to the same,
can lead to heterogeneity within the myocardium and hence serve a substrate to various arrthymias
• AUTONOMIC REMODELLING
Neural remodelling
BIOLOGICAL CLOCK
• EARLY MORNING NADIR
(12.00 AM TO 06.00 AM)
• MORNING PEAK
(06.00 AM TO 12.00 PM)
• MONDAY PEAK
DISORDERS OF IMPULSE FORMATION
• AUTOMATICITY
• TRIGGERED ACTIVITY
AUTOMATICITY
• Property of a fibre to initiate an impulse spontaneously, without need for an initial stimulation
Normal Automaticity
• Normal pacemaker mechanism behaving inappropriately
Eg:
1.Persistent sinus tachycardia at rest
2.Sinus Bradycardia during exercise
Abnormal Automaticity
• Escape of a latent pacemaker
• Due to abnormal ionic mechanisms, other pacemaker sites gain predominance over SA node
• Secondary to spontaneous submembrane Ca elevations, abnormal electric and ionic mileuleading to spontaneous depolarisation(Eg-Myocardial infarction)
Egs of abnormal automaticity
• Slow atrial rhythms
• Ventricular escape rhythms
• Digitalis assoc. Atrial tachycardias
• Accelerated Junctional tachycardia
• Idioventricular rhythms
• Parasystole
PARASYSTOLE
• Fixed rate asynchronously discharging pacemaker
• Not altered by the dominant rhythm (Entrance Block)
• Inter discharge interval is multiple of a basic interval
• May be Phasic or Modulated
Parasystole
DISORDERS OF IMPULSE FORMATION
• AUTOMATICITY
• TRIGGERED ACTIVITY
TRIGGERED ACTIVITY
• Initiated by AFTER DEPOLARISATIONS
o EARLY AFTER DEPOLARISATION
o DELAYED AFTER DEPOLARISATION
Not all after depolarisations reach the threshold potential (all or none response), but if they do, they would self perpetuate
EARLY AFTER DEPOLARISATION
• TYPE 1 -occurs during PHASE 2 of MAP
• TYPE 2 –occurs during PHASE 3 of MAP
• Substrate-
- prolonged plateau phase (action potential duration)
- leads to excess intracellular calcium,
-invokes a series of pumps (the Na+ pump), causing depolarisation
Egs of EAD
• LONG QT SYNDROME AND ASSOCIATED VENTRICULAR TACHYCARDIAS (inc. TdP)
- GENETIC CAUSES
- ACQUIRED CAUSES (class Ia and III antiarrythmics, Macrolide antibiotics)
• Magnesium and Potassium channel openers like Nicorandil suppress these EADs
LONG QT
TORSADES DE POINTESMolecular mechanism of TdP in inherited LQTS
Shah M et al. Circulation 2005;112:2517-2529
TdP
DELAYED AFTER DEPOLARISATION
• Occur after completion of Phase 4 of MAP
• Activation of calcium sensitive inward current
Eg:
• Mutations in RYR2 gene encoding Calsequestrinincreased sensitivity of RyR2 channel to catecholaminesDADCPVT
ABNORMAL CALCIUM HANDLING
Proposed scheme of events leading todelayed after depolarizations and triggered tachyarrhythmia
CPVTDAD-mediated CPVT. Mutations in the ryanodine receptor (RyR) result in leakage of Ca2+
from sarcoplasmic reticulum (SR) into cytoplasm.
Summary of “triggerred activity”
DISORDERS OF IMPULSE CONDUCTION
• Blocks
- tissue blocks, rate dependent blocks
- responsible for some of the bradyarrythmias
• Reentry
- heterogeneity in tissues
- responsible for most of the tachyarrythmias
Blocks
• Tissue becomes “inexcitable” and when there is no escape to the propagating impulse, it manifests as bradyarrythmias
• Can occur at any level of the conduction system
• Anatomic reasons (fibrosis-degenerative or as a consequence to the pathological process)
• Functional reasons (Rate dependent blocks)
Rate dependent blocks
• Deceleration dependent blocks
-Reduced ‘spontaneous diastolic depolarisation’ at slow rates is the cause
-? Role of digitalis
• Tachycardia dependent blocks
-post repolarisation refractoriness (incomplete recovery of
excitabilty when the next impulse arrives) of 1 or the other bundle branches, is the cause
BRADYCARDIA DEPENDENT BLOCK
Exercise induced LBBB
DISORDERS OF IMPULSE CONDUCTION
• Blocks
- tissue blocks, rate dependent blocks
- responsible for some of the bradyarrythmias
• Reentry
- heterogeneity in tissues
- responsible for most of the tachyarrythmias
REENTRY
• Heterogeneity in spread of depolaristionwithin a tissue is the cause
• Slow and Fast pathways
• Repeated Impulse reentry into the conduction system through an excitable pathway leads to sustaining of the tachycardia
reentrant tachycardia/ reciprocating tachy/circus movement/ echo beat
REENTRY
Types of Reentry
• Anatomical reentry- 2 distinct heterogeneous pathways of conduction, each with differrentelectrophysiological properties, creating a slow and a fast pathway- can occur at level of SA node, Atrium, AV node, Ventricle, Accessory pathways (WPW pattern)
• Functional reentry-dispersion of excitability, refractoriness or both within a tissue-Egs: Post Infarction, failing heart
Demonstration of Drug induced Reentry
TACHYCARDIAS CAUSED BY REENTRY
SINUS REENTRY
-SVT
-Usually less symptomatic
-in cases of refractory tachycardia, ABLATION may be required
Atrial Flutter-TYPICAL FLUTTER, counterclockwise moving from caudocranialdirection in the interatrialseptum
-recurrence can occur in cases of other pathways of reeentry, specially seen in cases like ASD with AFlutter
Atrial Flutter
-Slowing of conduction occurs in the posteromedialarea of the right atrium
-this location is used to ablate
Atrial Fibrillation-micro entry circuits due to spatio-temporal disorganisation within the atrium
-MULTIPLE WAVELET HYPOTHESIS
-anatomic remodelling
-electric remodelling of the atrium
-Role of Micro RNAs
-Ion channel abnormalities
-Familial AF (KCNQ1)
Heart Rhythm Volume 11, Issue 7, Pages 1229–1232, July 2014
Marshall bundle reentry: A novel type of macroreentrant atrial tachycardia
AV NODAL REENTRY-Sudden onset and termination
-Variation in cycle length “exposes” the AV nodal heterogeneity and stats the reentry
•SLOW-FAST pathway (Typical)
•FAST-SLOW pathway
•SLOW-SLOW pathway
AV REENTRYLocation of accessory pathways
-Accessory bundles of conducting tissue
“Preexcitation”impulses conducted to ventricles thru’ these pathways earlier than the usual oneWPW PATTERN
WPW PATTERN AND SYNDROME
VENTRICULAR TACHYCARDIAS MECHANISMS
• AUTOMACITY (rare)
• TRIGGERED ACTIVITY
- EAD TdP, Left Ventricular Fascicular Tachycardias
- DAD RVOT Tachycardias
• REENTRY
-Post MI, Heart failureFunctional reentry
-Brugada Syndrome
-ARVD
Fascicular VT
RVOT TACHYCARDIA
BRUGADA SYNDROME
BRUGADA PATTERN
-Phase 2 reentry
-Mutations in genes encoding Na+ channels (SCN5A gene)->alterations in Na channel currentheterogeneity in AP in RV epicardium
-ICDs are the only proven therapies to avert SCD in such pts.
• Importance of using PROPER ECG ELECTRODE POSITIONS and HIGH PASS FILTERS (0.05-0.35 HZ) during a recording of ECG
DRUG INDUCED BRUGADA
VENTRICULAR FIBRILLATION
• Maintained solely by reentry
• Numerous hypothesis
-The Mother-Rotor hypothesis
-Wandering wavelet hypothesis
• Calcium alternansAPDalternansT wave alternans
• Spatio-Temporal disorganisation
“Rotor Stability Separates Sustained Ventricular Fibrillation From Self-Terminating Episodes in Humans”
J Am Coll Cardiol. 2014;63(24):2712-2721. doi:10.1016/j.jacc.2014.03.037
SYNOPSIS
• Anatomy of the Conduction System
• Ion channels and Clinical Implications
• Myocardial Action Potential
• Basis of Arrythmogenesis
• ECG examples of Arrythmias
• Concept of Entrainment
OVERDRIVE PACING
• After cessation of pacing,
- It can increase the amplitude and shorten the cycle length of the complexes (overdrive acceleration) suggest the mechanism of arrythmia is DELAYED AFTER DEPOLARISATION
- It can terminate the underlying tachycardiasuggest the underlying mechanism of arrythmia is REENTRY
ENTRAINMENT
• “En-training” the tachycardia simply means increasing the rate of tachycardia by pacing
• Resetting of the reentrant circuit with the pacing induced activation
• Resumption of the intrinsic rate of the tachycardia when the pacing is stopped
• Implications:
-used to prove the reentrant mechanism of the tachycardia,
-used to locate the reentrant pathway
SUMMARY
• ANATOMY OF CONDUCTION SYSTEM
• IMPORTANT ION CHANNELS AND THEIR CLINICAL IMPORTANCE
• MYOCARDIAL ACTION POTENTIAL
• MECHANISMS OF ARRYTHMOGENESIS
• FEW CONCEPTS-
Overdrive Pacing, Entrainment,
Drugs Causing And Treating Arrythmias
CONCLUSION
“An attempt should be made to study the basis of each arryhthmia we come across, in order to terminate it with appropriate pharmacological/ intervention and also prevent its recurrence”
REFERENCES
• BRAUNWALD TEXTBOOK
• HURST TEXTBOOK
• ZIPES’ ELECTROPHYSIOLOGY
• LITERATURE SEARCH OF 2013-2014 ISSUES
“HEART RHYTHM”, “JACC”
THANK YOU