Non-Pacemaker Action Potentials
Unlike pacemaker cells found in nodal tissue within the heart, non-pacemaker cells have a true resting membrane potential (phase 4) that remains near the equilibrium potential for K+ (EK). The resting membrane potential is very negative during phase 4 (about -90 mV) because potassium channels are open (K+ conductance [gK+] and K+ currents [IK1] are high). As shown in the figure, phase 4 is associated with K+ currents, in which positive potassium ions are leaving the cell and thereby making the membrane potential more negative inside. At the same time, fast sodium channels and (L-type) slow calcium channels are closed.
When these cells are rapidly depolarized to a threshold voltage of about -70 mV (e.g., by an action potential in an adjacent cell), there is a rapid depolarization (phase 0) that is caused by a transient increase in fast Na+-channel conductance (gNa+) through fast sodium channels. This increases the inward directed, depolarizing Na+ currents (INa) that are responsible for the generation of these "fast-response" action potentials (see above figure). At the same time sodium channels open, gK+ and outward directed K+ currents fall as potassium channels close. These two conductance changes move the membrane potential away from EK (which is negative) and closer toward the equilibrium potential for sodium (ENa), which is positive.
Phase 1 represents an initial repolarization that is caused by the opening of a special type of transient outward K+ channel (Kto), which causes a short-lived, hyperpolarizing outward K+ current (IKto). However, because of the large increase in slow inward gCa++ occurring at the same time and the transient nature of IKto, the repolarization is delayed and there is a plateau phase in the action potential (phase 2). This inward calcium movement ICa(L) is through long-lasting (L-type) calcium channels that open up when the membrane potential depolarizes to about -40 mV. This plateau phase prolongs the action potential duration and distinguishes cardiac action potentials from the much shorter action potentials found in nerves and skeletal muscle.
Therefore, the action potential in non-pacemaker cells is primarily determined by relative changes in fast Na+, slow Ca++ and K+ conductances and currents. As described under the discussion on membrane potentials and summarized in the following relationship and in the figure to the right, the membrane potential (Em) is determined by the relative conductances of the major ions distributed across the cell membrane. When g'K+ is high and g'Na+ and g'Ca++ are low (phases 3 and 4), the membrane potential will be more negative (resting state in the figure). When g'K+ is low and g'Na+ and/or g'Ca++ are high, the membrane potential will be more positive (phases 0, 1 and 2) (depolarized state in the figure).
Em = g'K+ (−96 mV) + g'Na+ (+50 mV) + g'Ca++ (+134 mV)
These fast-response action potentials in non-nodal tissue are altered by antiarrhythmic drugs that block specific ion channels. Sodium-channel blockers such as quinidine inactivate fast-sodium channels and reduce the rate of depolarization (decrease the slope of phase 0). Calcium-channel blockers such as verapamil and diltiazem affect the plateau phase (phase 2) of the action potential. Potassium-channel blockers delay repolarization (phase 3) by blocking the potassium channels that are responsible for this phase.
Once an action potential is initiated, there is a period of time comprising phases 0, 1, 2, 3 and early phase 4 that a new action potential cannot be initiated (see figure at top of page). This is termed the effective refractory period (ERP) or the absolute refractory period (ARP) of the cell. During the ERP, stimulation of the cell by an adjacent cell undergoing depolarization does not produce new, propagated action potentials. This occurs because fast sodium channels remain inactivated following channel closing during phase 1. They do not change to their closed, resting (excitable) state until some time after the membrane potential has fully repolarized. The ERP acts as a protective mechanism in the heart by preventing multiple, compounded action potentials from occurring (i.e., it limits the frequency of depolarization and therefore heart rate). This is important because at very high heart rates, the heart would be unable to adequately fill with blood and therefore ventricular ejection would be reduced.
Many antiarrhythmic drugs alter the ERP, thereby altering cellular excitability. For example, drugs that block potassium channels (e.g., amiodarone, a Class III antiarrhythmic) delay phase 3 repolarization and increases the ERP. Drugs that increase the ERP can be particularly effective in abolishing reentry currents that lead to tachyarrhythmias.
Transformation of non-pacemaker into pacemaker cells
It is important to note that non-pacemaker action potentials can change into pacemaker cells under certain conditions. For example, if a cell becomes hypoxic, the membrane depolarizes, which closes fast Na+ channels. At a membrane potential of about 50 mV, all the fast Na+ channels are inactivated. When this occurs, action potentials can still be elicited; however, the inward current are carried by Ca++ (slow inward channels) exclusively. These action potentials resemble those found in pacemaker cells located in the SA node, and can sometimes display spontaneous depolarization and automaticity. This mechanism may serve as the electrophysiological mechanism behind certain types of ectopic beats and arrhythmias, particularly in ischemic heart disease and following myocardial infarction.