Anatomy and physiology of the sinus node

The sinoatrial node (SAN) is the dominant pacemaker structure in the mammalian heart. It is endowed with robust intrinsic automaticity, providing periodic electrical excitation with a cycle widely modulated by autonomic influences. A number of membrane channels and transporters contribute to the net membrane current supporting SAN electrical activity, whose periodicity is determined by the interplay of two oscillators termed ‘membrane’ and ‘calcium’ clock respectively. This chapter describes the structure of the SAN, the peculiarities of its electrical cycle, the nature and modulation of the underlying clocks, and SAN interaction with atrial muscle. Moreover, the features and determinants of the temporal variability of the pacemaker cycle, clinically used to assess autonomic balance, are briefly discussed.