Question 1

Describe and compare the action potentials from cardiac ventricular muscle cells and the sino-atrial node.

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College Answer

This question details an aspect of cardiac physiology which is well described in multiple texts. Comprehensive answers included both a detailed description of each action potential and a comparison highlighting and explaining any pertinent differences. The question lends itself to well-drawn, appropriately labelled diagrams and further explanations expressed in a tabular form. Better answers included a comparison table with points of comparison such as the relevant RMP, threshold value, overshoot value, duration, conduction velocity, automaticity, ion movements for each phase (including the direction of movement) providing a useful structure to the table. Incorrect numbering of the phases (0 – 4) and incorrect values for essential information (such as resting membrane potential) detracted from some responses.


Appropriately labelled diagrams? Tabular form? Who knew that these might be the keys to answering a CICM exam question.

Phases of the myocyte and pacemaker action potential

A Comparison of the Ionic Events
During the Cardiac Action Potentials
in the Myocyte and the Pacemaker Cell

Cell Ventricular Myocyte Pacemaker cell
Resting potential -90 mV -60 mV
Threshold Potential -70 mV - 40 mV
Phase 4
  • Resting potential
  • Stable plateau
  • Maintained by the Ik1  inward rectifying potassium current
  • Slow depolarisation
  • Maintained by the If "funny" sodium curent
Phase 0
  • Rapid depolarisation
  • Mediated by fast voltage-gated sodium channels
  • Slow depolarisation
  • Mediated by L-type calcium channels
Phase 1
  • Rapid repolarisation
  • Mediated by transient outward potassium currents (Ito) and the 
  • No Phase 1 in the pacemaker action potential
Phase 2
  • Prolonged plateau at ~ 0mV
  • Lasts ~ 100-200 msec
  • Mediated by L-type calcium channels
  • No real Phase 2 in the pacemaker action potential
Phase 3
  • Rapid repolarisation
  • Mediated by the Ikr, Iks and Ik1 potassium currents 
  • More gradual repolarisation
  • Mediated by the Ikr, Iks and Ik1 potassium currents 


Antoni, H. "Electrophysiology of the heart at the single cell level and cardiac rhythmogenesis.Comprehensive Human Physiology. Springer, Berlin, Heidelberg, 1996. 1825-1842.

Pinnell, Jeremy, Simon Turner, and Simon Howell. "Cardiac muscle physiology." Continuing Education in Anaesthesia, Critical Care and Pain 7.3 (2007): 85-88.

Bers, Donald M. "Cardiac excitation–contraction coupling.Nature 415.6868 (2002): 198-205.

Draper, Morrell Henry, and Silvio Weidmann. "Cardiac resting and action potentials recorded with an intracellular electrode." The Journal of physiology 115.1 (1951): 74-94.

Bers, Donald M. "Cardiac excitation–contraction coupling." Nature 415.6868 (2002): 198-205.

DiFrancesco, Dario. "Pacemaker mechanisms in cardiac tissue." Annual review of physiology 55.1 (1993): 455-472.

Noma, Akinori. "Ionic mechanisms of the cardiac pacemaker potential." Japanese heart journal 37.5 (1996): 673-682.

Grunnet, Morten. "Repolarization of the cardiac action potential. Does an increase in repolarization capacity constitute a new anti‐arrhythmic principle?." Acta physiologica 198 (2010): 1-48.