A novel conceptual model of heart rate autonomic modulation based on a small-world modular structure and heterogeneous innervation of the sinoatrial node

The current theory of cardiac pacemaker rate modulation by the autonomic nervous system is based on the concept that a primary pacemaker cell or a group of cells in the center of the sinoatrial node (SAN) can change its AP firing rate within a broad range, driving respective myocardium contractions to commensurate body demands. Experimental data show, however, that pacemaker cells are extremely heterogeneous, with different areas of the SAN or cell clusters specializing to drive APs at specific rates. Thus, higher heart rates under stress are mainly driven by cell clusters in superior SAN, whereas low rates by cell clusters in inferior SAN, with basal state rates generated somewhere in the middle of the node. Cells within different clusters feature different intrinsic electrophysiological and Ca cycling properties, sympathetic and parasympathetic innervation, and vasculature, thereby supporting effective shift of the system to an optimal rate (under given conditions) accompanied by respective shifts in the leading pacemaker site. Thus, the popular single-cell-based pacemaker theory does not capture this complex emerging paradigm of pacemaker function of SAN tissue revealed by recent experimental studies. Here we propose a more realistic, conceptual model of heart rate autonomic modulation based on these studies. Our new model (the gear model) simulates the SAN as a brain-like structure featuring a small world of loosely connected clusters (functional modules) of tightly coupled cells, modeled as Maltsev-Lakatta coupled-clock system. One module (the higher chronotropic gear) generates higher AP rates in basal state and under {beta}-adrenergic stimulation, but its activity is strongly suppressed by parasympathetic stimulation. The other module (the lower gear) generates lower rates and has low sensitivity to parasympathetic stimulation. Such modular, gear-like system reproduces the respective shifts of the leading pacemaker site observed experimentally and features a wide range of rate modulation and robust function whilst conserving energy. In perspective, future refinement and application of this new pacemaker tissue mechanism will provide better understanding of cardiac pacemaker function, its deterioration in aging and disease, and ultimately the creation of new therapies to treat sick sinus syndrome and other SAN function-related cardiac arrythmias.