Mary Boudreau Conover BSNed
- Brief Anatomy and Physiology---Inside the Heart
- Pacemaker of the Heart
- Exercise-Induced Sinus Tachycardia and its Benefits
- Observable Characteristics Of Sinus Tachycardia
- The “Atrial Kick”
- Summary
BRIEF ANATOMY AND PHYSIOLOGY---INSIDE THE HEART
The sinus node. Your
heart has kept you alive all this time with a nice normal rhythm at an
appropriate rate. The structure responsible for such a dependable
personal cardiac-history is called the sinoatrial (SA) node or sinus node.
It can only be defeated if invaded or overpowered. This article has
been written to acquaint you with the function of this little node
during all of the activities of your life, including your workout, when
it protects your organs by supplying you with an appropriate sinus
tachycardia.
The discovery of the sinus node was published in 19071,
describing a crescent-shaped area located within the uppermost wall of
the right atrium. It was later demonstrated that there is an artery
coursing through its length. The word “sinus” describes a curved,
hollow, sac-like structure, a designation that probably reflected what
Kieth and Flack could see with the equipment of the day in 1907.
Modern technology and electromechanical mapping has revealed it to be a
group of highly specialized cells tightly packed in connective tissue
with an “irregular contour, variable borders, and extensions”4 into the surrounding myocardium.
The
illustration rather dramatically represents the sinus node as a bright
yellow spot against a pretty pink background--not even close to
reality, but it does pinpoint its location fairly accurately. The
sinus node is actually embedded within the right atrial wall and not
plastered against the inside wall as shown in the illustration. You
will see it again in a more realistic animation below.
The atrioventricular (AV) node
is a group of special cells in the floor of the right atrium where the
sinus impulse is delayed slightly to allow for the atrial contraction
to be completed.
The His bundle
(pronounced “Hiss”) is the very important slender tract extending into
the ventricles from the AV node. It is the only normal electrical
connection between atria and ventricles. This link to an animated
illustration of cardiac electrical and mechanical activation may help
in the visualization of the cardiac conduction system and how the heart
responds to it. This is a complicated link, but well worth seeing.
Please click on the “forward” arrow at the bottom of the picture and
you will see a perfectly stunning animation of the normal sinus rhythm,
electrical and mechanical. The flash of light from SA node to the apex
of the heart represents the electrical current that powers the heart.
NOTE: It says “ventricular tachycardia” at the top of the illustration. Ignore it and enjoy.
Electrical System of the Heart
Papillary muscles and chordae.
The strange looking finger-like protrusions that you see inside the two
ventricles are diagrammatically illustrated below. They are strong
muscles (papillary muscles) extending into tough string-like tendons
(chordae) attached to mitral and tricuspid valve leaflets. Only one
valve leaflet is shown. The papillary muscles and the chordae keep the
valve leaflets from flipping up into the two atria during ventricular
contraction and are also thought to be important retaining the
ventricular shape and function2, 3. Click on the animation again and watch the papillary muscle and chordae at work. What an incredible creation!
Illustration courtesy of: Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York City, NY
PACEMAKER OF THE HEART
THE
pacemaker of the heart is the sinus node because it is automatic,
needing no stimulation from elsewhere. There are other cells located
geographically lower in the heart (bundle of His) that are capable of
firing automatically, but the sinus node does it best and dominates all
other contenders. It also adjusts its firing rate so that the speed at
which the blood is pumped (heart rate) meets the needs of the body in
all the varied activities of life---sleeping, eating, running,
relaxing, splitting logs, climbing the face of El Capitan, skiing the
steeps, surfing Mavericks, making love, fleeing danger, fighting
tigers, chasing buffalo, or exercising CrossFit-style--intensely. Its
rhythm normally changes to accommodate every situation you may throw at
it and it does so smoothly—never abruptly---no sudden starts and stops.
This last property distinguishes it from most abnormal tachycardias.
Muscle cells of the heart. The
muscle cells of the heart are not normally capable of automaticity.
Their sole functions, other than that of a container for blood, are to
respond to the electrical currents, pass it on, contract, and
relax—restored and ready for the next cycle. They simply wait for the
next impulse to arrive—and so it goes, each beat depending on a
stimulus from the sinus node.
EXERCISE-INDUCED SINUS TACHYCARDIA AND ITS BENEFITS
Sinus
tachycardia is strictly defined as a rate of 100 beats/min or more and
is called an “arrhythmia” by traditionalists and a “dysrhythmia” by
purists. These designations for this particular rhythm are unfortunate
because they fly in the face of appropriate exercise-related sinus
tachycardia—certainly NOT an arrhythmia (without rhythm) or a
dysrhythmia (disturbed rhythm). Every day that you do an intense,
tough, CrossFit workout that tachy is yours! It is the normal response
of the heart to signals from the brain that you need more oxygen.
We don’t worry about our heart rate during workouts. Are we OK with that? You bet! . Studies
have shown that aerobic interval training and the functional sinus
tachycardia associated with it improve micro circulation, the health of
the lining of our coronary arteries, and myocardial function at the
cellular level 5.
That’s a boon, considering our CF passion for anaerobic/aerobic
workouts! In fact, mixed-sports (aerobic and anaerobic) athletes and
elite endurance (aerobic) athletes survive longer than the general
population; fewer cases of cardiovascular disease are thought to be the
primary reason 6.
Even in those athletes with cardiovascular disease who have sustained a
heart attack, some of the negative effects following the event are
reversed in hearts preconditioned with tachycardia7, 8.
OBSERVABLE CHARACTERISTICS OF SINUS TACHYCARDIA
All
other forms of tachycardia are abnormal and not always well tolerated
by your brain or your heart. So it behooves us to know this friend of
ours so that we can recognize the unfriendlies, for others and
ourselves.
There
are interesting physical clues that give the unfriendlies away. To
understand these clues we will begin with an understanding of the
characteristics of our friend—sinus tachycardia.
Acceleration. In
healthy young adults during strenuous physical exercise the rate of the
sinus node may be as much as or even more than 200 beats/min. The max
rate during exercise may decrease with age to less than 140 beats/min.
When the sinus rate accelerates in response to exercise it does so
gradually and settles into a rapid, regular rhythm. Your respirations
reflect your heart rate. You all know the feeling---open mouth,
sucking air, spread eagle on the floor.
Deceleration.
When the workout is completed and the physiological needs no longer
exist, the heart rate decelerates along with respirations. The
deceleration is easier to determine than the acceleration at the
beginning of a workout—a busy time. However, at the end of a workout,
it is fairly easy to put your fingers on a pulse and feel the heart
rate become slower and slower. Try this after your own workout just to
get the feel of normal deceleration of the sinus node rate in a healthy
person. Acquaint yourself well with the normal and you will more
easily recognize the abnormal.
Rhythm.
A sinus rhythm is regular, but can change slightly with
respirations—increasing with inspiration and decreasing with
expiration, especially in athletes and children. Sometimes we may feel
our hearts “skip a beat”. The “skipped beat” is actually the pause
following a premature beat generated from a source other than the sinus
node (an ectopic focus). It is not uncommon and is not treated in
healthy individuals.
THE “ATRIAL KICK”
One
reason that sinus tachycardia doesn’t land you flat on your back is
because the electrical activation and contraction of the atria and
ventricles are sequential. The ventricles, as with other muscles,
perform best when stretched just prior to contraction. For this to
happen, the atria contract before the ventricles, pushing their
contents into the already passively filled ventricles and providing not
only a stretch but also an important extra boost of blood known as the “atrial kick.” Hearts
that are deprived of this atrial kick, such as those with no organized
atrial contractions (atrial fibrillation), lose approximately 10% of
their cardiac output---slows one down a bit.
SUMMARY
- Sinus rhythm is regular; no sudden stops and starts.
- During
sinus rhythm the atria contract before the ventricles—providing
additional blood to fill the ventricular chambers and an extra stretch
for the ventricular myocardium, resulting in a robust contraction and
an excellent cardiac output.
- Sinus
tachycardia increases and decreases its rate gradually---never abruptly
and always in harmony with the need of the body for oxygen.*
- The rate of respirations increases in tandem with the heart rate.
REFERENCES
- Keith A, Flack M: The form and nature of the muscular connections between the primary divisions of the vertebrate heart. J Anat Physiol 1907; 41:172.
- Rodriguez F, Langer F, Harrington KB et al. Importance
of mitral valve second-order chordae for left ventricular geometry,
wall thickening mechanics, and global systolic function. Circulation 2004 September 14;110(11 Suppl 1):II115-II122.
- Rodriguez F, Langer F, Harrington KB et al. Effect of cutting second-order chordae on in-vivo anterior mitral leaflet compound curvature. J Heart Valve Dis 2005 September;14(5):592-601.
- D Sánchez-Quintana, JA Cabrera, et al: Sinus node revisited in the era of electroanatomical mapping and catheter ablation. Heart 2005 91(2):189-194.
- Domenech RJ. Sanchez G, Donoso P, et al: Effect of tachycardia on myocardial sarcoplasmic reticulum and Ca2+ dynamics: a mechanism for preconditioning? Journal of molecular and cellular cardiology, 2003; 35: 1429-1437.
- Teramoto M, Bungum TJ: Mortality and longevity of elite athletes. J Sci Med Sport. 2009 Jun 30; Department of Sports Education Leadership, University of Nevada, Las Vegas, USA.
- Domenech RJ, Sanchez G, et al: Effect of tachycardia on myocardial sarcoplasmic reticulum and Ca2+ dynamics: a mechanism for preconditioning? Journal of Molecular and Cellular Cardiology 2003, vol. 35, no12, pp. 1429-1437.
- Kemi OJ, Ceci M, Condorelli G, et al: Myocardial sarcoplasmic reticulum Ca2+ ATPase function is increased by aerobic interval training. Institute of Biomedical and Life Sciences, University of Glasgow, UK. Eur J Cardiovasc Prev Rehabil. 2008; 15(2):145-148.
ACKNOWLEDGEMENTS
Coach Mark Rippitoe
(Wichita Falls Athletic Club, Texas) reviewed the early formation of
this article and suggested an expansion of the discussion on the sinus
node. The reference from Sánchez-Quintana et al was particularly
enlightening
Tara Muccilli, Michelle Mootz, and Eva Twadorkens from CFSCC each added their own unique critique and helped immensely with their reviews.
mc 7/28/09