Sinoatrial Node (SA Node)

Located in the upper right atrium near the inlet for the superior vena cava, serves as the predominant pacemaker for the heart with rates usually of 60-100/minute.

The SA node, usually the dominant pacemaker, is located in the right atrium at the opening of the superior vena cava. The SA (sinoatrial) node is a clump of hundreds of specialized cardiac cells that have the ability to self-initiate an electrical impulse. This pacemaking ability, called automaticity, makes the SA node a pacemaker site in the heart.

As a general rule, the site in the heart that is able to self-generate the quickest rate, RULES the heart. This site is almost always the sinoatrial node (SA node). Thus, the SA node is often called the dominant pacemaker. If an ectopic site (site other than the SA node) begins to fire faster than the SA node, the ectopic site tends to drive the heart.

The SA node initiates an electrical impulse at a rate faster than other pacemaker sites (see Figure 3.2). In the heart, the pacemaker which fires at the quickest pace takes control of heart rate. This is why the SA node is the “dominant pacemaker”. A cardiac rhythm that originates from the SA node is called a sinus rhythm.

The SA node normally generates electrical impulses at 60-100/minute. This rate tends to increase with sympathetic stimulation (norepinephrine and epinephrine) and slows with parasympathetic stimulation (acetylcholine and the Vagus nerve). Therefore, Vagal stimulation can slow the SA node to rates below 60/minute causing a sinus bradycardia. Sympathetic stimulation can cause rapid sinus rhythms called sinus tachycardias.

Figure 3.2 Pacemaker Sites and Normal Rates

These are typical heart rates from various pacemaker sites. Heart rates can vary, though, for each site above and below the range specified. Note that the typical pacemaker rate decreases as the distance from the SA node increases. Lower pacemakers serve as “back-up” in case higher pacemakers fail. The bundle branches and the Purkinje network (both from the ventricles) typically provide an exceptional slow heart rate that is often associated with poor cardiac output. Note also that the absence of atrial activity results in a loss of atrial kick, impacting an already low cardiac output further.

1. Six Second ECG Guidebook (2012), T Barill, p. 47-48, 205

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