Health and medicine
- Membrane potentials - part 1
- Membrane potentials - part 2
- Permeability and membrane potentials
- Action potentials in pacemaker cells
- Action potentials in cardiac myocytes
- Resetting cardiac concentration gradients
- Electrical system of the heart
- Depolarization waves flowing through the heart
- A race to keep pace!
- Thinking about heartbeats
- New perspective on the heart
Thinking about heartbeats
Find out what happens when things move very slowly through the AV Node! Rishi is a pediatric infectious disease physician and works at Khan Academy. Created by Rishi Desai.
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- Are escaped beats the same as ectopic beats?(4 votes)
- no, ectopic just means out of place, and that means that there is another group of cells in the myocardium doing its own thing(creating action potentials) outside the usual heart conduction system, whether escaped beats come as you saw from a delay of the heart conducting system.(6 votes)
- My doctor has commented occasionally that he can hear a "slight murmur" when listening with his stesthascope. What is a "murmur"', or "slight murmur"?
- The most common heart murmurs have minimal clinical significance and are caused by physiologic states that result in higher-than-normal blood flow through the heart, like after periods of exercise, being pregnant, growing quickly (like during adolescence), or having anemia (low blood count) or fever. Other causes have to do with the heart itself and are more likely to be (but are not always) clinically significant, like having a hole in the heart (a septal defect, like muhammad pointed out) or a problem with one of the valves.
Many doctors classify the intensity of a murmur with a 6-point system done in Roman numerals (i.e. I-VI), with I being barely audible with a stethoscope, II easily audible, III loud, IV loud and with a little vibration (called a "thrill"), V loud enough to hear with just part of the stethoscope end touching the chest, and VI loud enough to hear with the entire stethoscope OFF the chest. In my practice, I would tell a patient with a grade I or II murmur that it was "slight" (although it might mean something different with YOUR doctor). Slight murmurs usually don't have too much clinical significance, but they ARE important to note because if a doctor hears them change in character, it can help to make important diagnoses.(8 votes)
- @2:50you explain that the relationship between conduction velocity and the action potential is the slope of phase 0, and that the steeper that slope, the faster the conduction. But, in the previous video you showed that the slope of phase 0 was the same for all three conduction sites. Did you mean the slope of phase 4, as that is where they differ in Na+ permeability?(3 votes)
- I was also confused about this - in relation to previous videos where you said that the signal travels much faster in pacemaker cells than in myocytes, but then why isnt the slope in phase 0 steeper in the pacemaker cells than in the myocytes ?(3 votes)
- How is the 0.1 second delay in the AV node accomplished? Are there proportionately fewer gap junctions and so fewer avenues for ions to permeate into those nodal cells? Are there more ion pumps so that there are greater gradients and so it takes longer to hit the typical thresholds? Are the thresholds somehow raised? What the heck?(2 votes)
- I think it's because of the number of cells in the node. There are more cells woven thru eachother, so there are more cells that needs to be activated before the signal is given thru to te Bundle of His. It's a question of numbers.(1 vote)
- At the end, Rishi Desai mentioned 'Escape Beats'. What causes them, and what effect do they have on the heart?(1 vote)
- Most heart cells have an automatic depolarization. This is caused by ions "leaking" through channels during the diastolic phase (resting phase). Think of these diastolic "leaks" as little clocks. When the diastolic potential gets to a specific threshold, it causes and action potential which can proprogate throughout the heart. In a normal heart, the SA node has the quickest spontneous depolarization and induces the normal heart beat. If the SA node is not functioning, or the AV node is blocked; then the next quickest spontenous depolarization typically comes from the HIS/Purkinje system - these patients have what is called a junctional rhythm. If the His/Purkinje system is not functioning, then patients may have a ventricular escape - a spontaneous depolarization from the ventricle that maintains the heart beat, though this would typically be very slow.(2 votes)
- Is the AV rhythm only manifest in relation to, i.e., following, the start of the abnormal delay?(1 vote)
- didnt understand this topic.(1 vote)
- Is this first degree heart block.(1 vote)
- Why does the speed of the signal increase from the SA node to the BoH. Are more calcium ions being added by the AV node?(1 vote)
- If I got it right the AV node doesn't "know" that the SA node is firing so there are two simultaneous rhythms.
So in the first 4 seconds the rhythm isn't regulated by the SA nor the AV node. But are there 10 or 8 beats? The ones at 2 s and 4 s are simultaneous or not?(1 vote)
So I know we talked about different pacemakers in the body, but I thought it'd be fun to revisit that and show you an interesting example. So let's start out by laying out the table we'd set up before. We talked about the heart rate in beats per minute, and we talked about the heartbeat itself-- the length of the heartbeat, and we'd measured the heartbeat in terms of seconds. And you remember, there's a nice little relationship between the two of these, because if the heartbeat actually gets shorter, then you can have more heart beats in a minute. And so of course, then the heart rate goes up. So that's a relationship that explains how it is that our heart rate goes up and down. And we talked about the SA node, the AV node, and the bundle of His. And we said starting with the SA node, the heart rate was somewhere between 60 and 90. And I think I'd chosen 90, just because that was a nice, easy number to do math with. And we had said that the heart beat is about 0.66 seconds. So that's the length of a heartbeat there. And then we have the AV node. I'm just going to quickly go through this. I know this is recap for you if you've seen the other video. If you haven't, then these numbers come from basically dividing beats per minute down into seconds. And so then each beat then would be one second for the AV node. And finally, we did the bundle of His. And I think I've started trying to take a shortcut in writing bundle of His into just BoH. And that looks something like this. And those underlying numbers are the numbers I'm using to calculate the heartbeat lengths. So that's basically what we had come up with. And we had also talked about the idea of having delays. You actually need time for the pulse to be in transit basically. And so, I'm actually going to add a third column to our little table here. And there really is no delay here, because the SA node is where things are starting. So let me actually just keep my colors the same. And then the AV node, we know that there's a small delay, because things do move pretty quick. So we said that here, it'd be something like 0.04 seconds. So you can see that it's actually pretty quick getting from the SA node to the AV node. But then it gets even faster as you get down to the bundle of His. It actually takes only about 0.005 seconds. So it gets really, really fast. And remember that this transit speed, this is really related to conduction velocity. So how fast is the signal getting conducted? So we call this conduction velocity. And the relationship between conduction velocity and the action potential is the slope of phase 0. Remember, the more steep phase 0 is, the faster something is going to go from cell to cell to cell. And actually, that brings up a good point, because in the AV node, there's a huge delay built in, because the conduction is so darn slow. And so you have to actually remember that there's this 0.1 second delay. And generally speaking, I think of 0.1 seconds as almost nothing, but when you compare it to 0.005 seconds, because that's the transit time-- that's how long it takes the signal to get down, we said from the AV node down to our particular bundle of His cell-- then all of a sudden, this delay is looking enormous. By comparison, this looks like a really big, big number. And let me just write transit here as well. So this is time for movement. And then the delay is simply getting through the AV node itself. So this is all just rehashing what we've talked about before. And finally, just to get at least a drawing down, because I like to draw, we have our SA node here. And we have our AV node here. And we have our bundle of His over here. And let me draw it half the distance, somewhere like this. And remember, this is the direction of flow. We're basically trying to move this way. And again, this way. So let me actually jump into something slightly new. So let's assume for a second-- this is a thought experiment-- that instead of 0.04 seconds, I'm just going to focus on these two right now. Instead of 0.04 seconds, let's say that it took 100 times as long. For some reason, let's say that transit time for some reason, we don't know why, let's say it takes 100 times longer. So this ends up being 4 seconds, right? 0.04 times 100 is 4 seconds. So let's say it takes about 4 seconds, for some reason, to get a signal from the SA node to the AV node. Well, what would that mean for us? What would that look like exactly? And I think you'll start seeing some interesting lessons from this little thought experiment. So, if that was the case, if it was actually taking about 4 seconds to get from one point to another, let's now draw out a timeline. This is a little time line, and this timeline starts at 0 seconds. And then you have, let's say, 1 second here, 2 seconds, 3-- I'm just going to see how far this goes-- 4, 5, and let's go to 6. So, this is 6. Seconds And we're going to follow what happens over 6 seconds. So let's imagine now we keep track of our SA node up here. And we're going to keep track of our AV node down here. So at time 0, let's imagine that everything is beginning. And we watch our SA node, let's start with that one first. Well, at 2/3 of a second-- because that's about how long it takes, we calculated-- we would get our first action potential, or a heart beat would go through, right? First beat. And that would then try to make its way towards the AV node. So this one is going to try to make its way towards the AV node. But we know it takes 4 seconds to get there. Now, what happens after that? Well, you'd have another beat let off. The first one hasn't actually made it to the AV node, but the second one is already done by that point. And you'd have a third beat that goes through by that point. And so really, we're counting these action potentials that are going through the SA node. And they just keep going through. They're just going to keep flowing through here. And they're going to all just continue and basically, just what are we going to get? A total of probably 9, right? We're going to get 9 signals sent off. Now, take each of them is going to take 4 seconds to get to the AV node. So when will this first one get to the AV node? This very first one will get to the AV node somewhere around here, because that's 4 and 2/3 of a second. So at 4 and 2/3 of a second, this one-- let me somehow show you without making this too messy-- will make it to the AV node right here. Of course at that time, the SA node itself is letting out its seventh action potential, but that very first one will get there at that point. Now the AV node, is it going to sit around and wait for 4 and 2/3 of a second to just go by and not do anything? No way, right? There's no way, because what it's going to do is it's going to say well, let's wait for a signal from the SA node. And at this point, it's going to say well, nothing arrived from the SA node, so I'm going to let off my own signal. And it's going to keep doing this. So it's going to go on its own rhythm now. So 2, 3, so all this time, the AV node is on its own rhythm. And then finally, before AV node is able to fire off its own fifth action potential by itself, a signal arrives from the SA node, this red arrow that I drew in. And so it'll say, oh wait. We just got some positive ion passed through the electrical conduction system. So let's go with it. So it'll have a signal there. And then now, it'll have another one here, because what happens at that point? Well, you have this guy arrives . He took 4 seconds, and he arrives right there. And then this guy is going to arrive after that. He's going to arrives right there. So you see they start arriving. And so, once they start arriving, then you get back onto what looks like a normal rhythm. And so, it's interesting because you basically, as a result of this long delay, have a phenomenon where for awhile, the AV node is doing its own thing over here. And then after that, the SA node catches up. And then it continues on what would look like a normal sinus rhythm. And so, sometimes you'll hear the term escape beats or escape rhythm. And so that's what these are, these are escape beats, meaning they have escaped the normal flow of electrical conduction, which starts with the SA node. So, hope that was helpful.