Cardiac pacemaker discharge at about 40-60 beats per minute, and are called the "secondary pacemaker". Further down the electrical conducting system of the heart is the Bundle of His. The left and right branches of this bundle, and the Purkinje fibres, will also produce a spontaneous action potential at a rate of 30-40 beats per minute, so if the SA and AV node both fail to function, these cells can become pacemakers. It is important to realize that these cells will be initiating action potentials and contraction at a much lower rate than the primary or secondary pacemaker cells. The SA node
Milrinone of the cardiomyocytes therefore increasing the rate at which cells can depolarize and generate contraction. PKA also phosphorylates components on myofilaments allowing actin and myosin to interact more easily and thus increasing contractility and the inotropic state of the heart. Milrinone allows stimulation of cardiac function independently of β-adrenergic receptors which appear to be down-regulated in those with heart failure. In recent years many studies have been performed showing that milrinone use may present potential adverse side effects in heart failure patients. Milrinone Milrinone, commonly known and marketed under the brand name Primacor, is a medication used in patients who