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ECG tutorial: Physiology of the conduction system

OfficialreprintfromUpToDate
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ECGtutorial:Physiologyoftheconductionsystem
Author
JordanMPrutkin,MD,
MHS,FHRS

SectionEditor
AryLGoldberger,MD

DeputyEditor
GordonMSaperia,MD,
FACC

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jun2015.|Thistopiclastupdated:Dec24,2013.
INTRODUCTIONThecardiacconductionsystemisdesignedforelectricalimpulsecreationand
propagation.Itallowsforinitiationofimpulsesintheatrium,slowedconductionintheatrioventricular(AV)
node,andrapidpropagationthroughtheHisPurkinjesystemtoallowsynchronouscontractioninthe
ventricles.Layersofredundancyoccur,sothatifoneportionisdamaged,theremaybeotherareasthatcan
compensateforthelossoffunction.
Cardiaccellshavetheinherentpropertyofspontaneousdepolarization,whichcreatesthecardiacimpulse.
Cellswithinthesinusnodehavethefastestrateofspontaneousdepolarization,and,therefore,thesinus
nodeisthemainpacemakerregionoftheheart.TheAVnodehasthesecondfastestrateofspontaneous
depolarization,whichallowsittocreateanescaperhythmifthesinusnodeisdiseased.
ATRIALACTIVATIONThesinusnode(themostproximalpartoftheconductionsystem)exhibitsthe
mostautomaticityandfunctionsasthedominantpacemakerinnormalcircumstances.Thisstructure
generatesaslowactionpotential,mediatedbycalciumcurrents,thatexitsthenodeandactivatestheatrial
myocardium.(See"Myocardialactionpotentialandactionofantiarrhythmicdrugs".)Theatrialmyocardium
actionpotentialhasarapidupstroke,mediatedbysodiumions(figure1)thathelptoquicklytransmitthe
signal.
Severalpreferentialtractsexistintheatriatomorequicklyspreadelectricalsignals[1].Intherightatrium,
theseincludethecristaterminalisandpectinatemuscles.TheBachmanbundlebeginsanteriortothe
superiorvenacavaandcrossesthesuperiorinteratrialseptumtofacilitaterighttoleftatrialconduction.A
superiorpulmonarybundleandseptoatrialbundlespeedconductionintheleftatrium.
Astheatriumisdepolarized,a"P"waveistranscribedonthesurfaceelectrocardiogram(figure2).Sincethe
sinusnodeisinthesuperiorrightatrium,thesignalgoesfromsuperiortoinferior,anteriortoposterior,and
righttoleft.ThePwaveisuprightandslightlynotchedinallofthelimbleads,withtheexceptionofaVR
whichhasanegativePwave.TheprecordialleadsalsoshowanuprightPwave,althoughinleadsV1and
V2thePwaveisusuallybiphasicaninitialpositivefollowedbyanegativedeflectionreflectsdepolarization
oftherightatrium(whichisanterior)andthentheleftatrium(whichisposterior).
ATRIOVENTRICULARNODEANDBUNDLEOFHISACTIVATIONAfteratrialactivation,theimpulse
reachestheatrioventricular(AV)node.Thisstructuregeneratesaslowcalciummediatedactionpotential
(figure1).Thus,thereisadelayinimpulsetransmissionthroughthisstructure.
OncetheactionpotentialtraversestheAVnode,itactivatestheproximalportionofthebundleofHis,a
specializedconductingtissuethatgeneratesafastactionpotential.Thus,impulseconductionthroughthis
structureisrapid.ThisperiodoftimefromtheendofthePwavetothebeginningoftheQRS,duringwhich
thereisactivationofboththeAVnodeandbundleofHis,istermedthePRsegment.ThePRinterval,in
contrast,includesthePwave(atrialactivation)aswellasthePRsegment(figure2).BecausetheAVnode
andbundleofHisaresmall,thereisnoelectricalactivitymanifestonthesurfaceelectrocardiogram(ECG)
fromtheirconduction.TheelectricalactivitythatisoccurringduringthePRintervalcanbemeasured,
however,usingintracardiacelectrodesduringelectrophysiologictesting.(See"Invasivecardiac
electrophysiologystudies".)AbnormalitiesofconductionintheAVnodeandbundleofHisaremanifeston
thesurfaceECGasfirst,second,orthirddegreeAVblock.(See"ECGtutorial:Atrioventricularblock".)
VENTRICULARACTIVATIONAfterimpulsetransmissionthroughthebundleofHis,theimpulseis
conductedtotherightandleftbundlebranchestheseareextensionsoftheHisbundlethatgenerateafast
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actionpotential(figure1).TheimpulsetravelsthroughthebundlesandthePurkinjefibernetwork,
generatingafastactionpotentialandresultinginrapidactivationanddepolarizationofthemyocardiumof
therightandleftventricles.Theimpulseenterstheventricularmyocardiumfirstfromaseptalportionofthe
leftbundle.Thus,theleftintraventricularseptumisthefirstpartoftheventricletobecomedepolarized,
resultinginthefollowingelectrocardiogram(ECG)appearanceoftheQRS(figure2):
AninitialsmallseptalQwaveonthesurfaceECGleadsthatmeasureelectricalactivitytowardtheleft
sideoftheheart(leadsI,aVL,andV4toV6)sincetheimpulseismovingawayfromtheseleads.
AsmallinitialRwaveintheleadspointedtowardtherightsideoftheheart(aVR,V1,andV2)sincethe
impulseismovinginthedirectionoftheseleads(figure1).
Sincethemassoftheleftventricleismuchgreaterthanthatoftheright,thenormalECGprimarilyreflects
leftventriculardepolarization(figure2).Theimpulsespreadsfromtheseptumtothelateralwallinarightto
leftandsuperiortoinferiordirection,therebygeneratingthefollowingECGappearance:
AtalluprightRwaveinthelimbleadsI,II,aVFandtheprecordialleadsV3toV6sincetheimpulseis
movingtowardstheseleads.
AdeepnegativedeflectionorSwaveintheleadsthataredirectedtotheseptumandrightsideofthe
heart(aVR,V1,andV2)sincetheimpulseismovingawayfromtheseleads.
Thelastpartoftheleftventricletobecomedepolarizedisthehighlateralregion.Thus,thelastpartofthe
QRSmaybereflectedonthesurfaceECGasasmallterminalSwaveinleadsI,II,aVFandV4toV6,anda
smallr'inleadaVRandoccasionallyV1andV2.
REPOLARIZATIONAftertheentiremyocardiumoftheleftandrightventriclescompletesdepolarization,
thereisaperiodoftimeimmediatelypriortothefinalphaseofrepolarizationorrecoveryduringwhichthere
isnoapparentelectricalactivityonthesurfaceelectrocardiogram(ECG),theisoelectricSTsegmentphase.
Duringthisperiod,correspondingtophase2oftheactionpotential,theventricularmyocytesareatabout
thesamepotential,sononetcurrentflowoccurs.Thereafter,theventricularmyocardiumundergoesthefinal
phaseofrepolarization,generatingaTwaveonthesurfaceECG(figure2).Sincethewaveofrepolarization
occursfromtheepicardiumtotheendocardiumandisofoppositeelectricalchargeasdepolarization,itis
usuallypositiveontheECG.Thelastwaveforminthiscycle,usuallymostapparentinthemidprecordial
leads,istheUwave,whichisofuncertainoriginbutmayrepresentrepolarizationoftheHisPurkinjesystem
orofthemidmyocardialMcells.
SUMMARY
Cardiaccellspossessinherentspontaneousautomaticity.Thetissuethatpossessesthegreatest
degreeofautomaticity(eg,hasthefastestrateofspontaneousdepolarization)functionsasthe
dominantpacemakeritgeneratesaspontaneousactionpotentialthatisconductedalongtherestof
theconductionsystem,activatingthemyocardiuminauniformfashion.(See'Introduction'above.)
Thesinusnodeexhibitsthefastestautomaticityandinitiateseachbeatinmostcases.Electricalactivity
spreadsfromthesinusnodetotheatrium,causingaPwaveontheelectrocardiogram(ECG).(See
'Atrialactivation'above.)
Afteratrialactivation,theimpulsereachestheatrioventricular(AV)node.Thereisrelativelyslow
transmissionoftheelectricalcurrenthere.OncetheactionpotentialtraversestheAVnode,itactivates
theproximalportionofthebundleofHis.AlthoughthereisnomanifestationofAVnodalorbundleof
HisactivationonthesurfaceECG,conductionthroughthesestructuresoccursduringthePRsegment.
ThePRinterval,whichalsoincludesatrialconduction,iscomprisedofthePwaveaswellasthePR
segment.(See'AtrioventricularnodeandbundleofHisactivation'above.)
Sequentialactivationofdifferentpartsoftheleftandrightventriclesfollowsandcausesthe
characteristicQRScomplex.Astheleftventricularmusclemassisfargreaterthanthatoftheright
ventricle,theQRScomplexprimarilyrepresentsleftventriculardepolarization.
AftertheQRS,theventricularmyocytesnormallyremainataboutthesamepotential,sothesurface
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ECGreturnstobaselineSTsegmentphase.Thereafter,theventricularmyocardiumundergoesthe
finalphasesrepolarization,generatingaTwaveandsometimesasmallUwave.(See'Repolarization'
above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1. ZhaoJ,ButtersTD,ZhangH,etal.Animagebasedmodelofatrialmusculararchitecture:effectsof
structuralanisotropyonelectricalactivation.CircArrhythmElectrophysiol20125:361.
Topic2116Version5.0

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GRAPHICS
Actionpotentialsgeneratedbydifferentpartsof
conductionsystem

Thesinoatrial(SA)andatrioventricular(AV)nodesgenerateaslow
actionpotential,mediatedbycalciumions.Incomparison,thetissuesof
theatria,ventricles,andtheHisPurkinjesystemgenerateafastaction
potentialmediatedbysodiumions.Sequentialactivationofthese
structuresresultsinthecharacteristicwaveformsvisibleonthesurface
ECG.TheAVnodeandbundleofHisaresmallstructuresasaresult,
noelectricalactivityisrecordedonthesurfaceECGduringtheir
activation.
Graphic61989Version2.0

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FormationofthemajordeflectionsontheECG

Theelectricalimpulseisinitiatedinthesinusnodeandthenactivatestheright
andleftatria,generatingthePwave.Impulseconductionthroughthe
atrioventricular(AV)nodeandbundleofHis,whicharesmallstructures,does
notgenerateanyECGactivitythisperiodof"electricalsilence"isthePR
interval.Thefirstpartoftheventricletobedepolarizedistheleftsideofthe
interventricularseptum,producingasmallseptalQwave,followedby
depolarizationoftheremainderoftheventricularmyocardium,generatingthe
fullQRScomplex.TheTwaverepresentsventricularrepolarization.AUwave
maybepresent,representingrepolarizationoftheHisPurkinjesystem.
Graphic59933Version2.0

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Disclosures
Disclosures:JordanMPrutkin,MD,MHS,FHRSGrant/Research/ClinicalTrialSupport:Boston
Scientific[Heartblock(PacemakersandICDs)]St.JudeMedical[Suddendeath(Pacemakersand
ICDs)].AryLGoldberger,MDNothingtodisclose.GordonMSaperia,MD,FACCNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmust
conformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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