Ye Y, Lin Y, Perez-Polo R, Huang MH, Hughes MG, McAdoo DJ, Manickavasagam S, Uretsky BF, Birnbaum Y. Enhanced cardioprotection against ischemia-reperfusion injury with a dipyridamole and low-dose atorvastatin combination. Am J Physiol Heart Circ Physiol 293: H813-H818, 2007. First published April 6, 2007; doi:10.1152/ajpheart.00210.2007.-Atorvastatin (ATV) limits infarct size (IS) by activating Akt and ecto-5-nucleotidase, which generates adenosine. Activated Akt and adenosine activate endothelial nitric oxide synthase (eNOS). When given orally, high doses (10 mg/kg) are needed to achieve full protection. We determined whether dipyridamole (DIP), by preventing the reuptake of adenosine, has a synergistic effect with ATV in reducing myocardial IS. In this study, rats received 3-days of the following: water, ATV (2 mg ⅐ kg Ϫ1 ⅐ day Ϫ1 ), DIP (6 mg ⅐ kg Ϫ1 ⅐ day Ϫ1 ), or ATV ϩ DIP. In addition, rats received 3-days of the following: aminophylline (Ami; 10 mg ⅐ kg Ϫ1 ⅐ day Ϫ1 ) or Ami ϩ ATV ϩ DIP. Rats underwent 30 min of myocardial ischemia followed by 4 h of reperfusion (IS protocol), or hearts were explanted for immunoblotting. As a result, IS in the controls was 34.0 Ϯ 2.8% of the area at risk. ATV (33.1 Ϯ 2.1%) and DIP (30.5 Ϯ 1.5%) did not affect IS, whereas ATV ϩ DIP reduced IS (12.2 Ϯ 0.5%; P Ͻ 0.001 vs. each of the other groups). There was no difference in IS between the Ami alone (48.1 Ϯ 0.8%) and the Ami ϩ ATV ϩ DIP (45.8 Ϯ 2.9%) group (P ϭ 0.422), suggesting that Ami completely blocked the protective effect. Myocardial adenosine level in the controls was 30.6 Ϯ 3.6 pg/l. ATV (51.0 Ϯ 4.9 pg/l) and DIP (51.5 Ϯ 6.8 pg/l) caused a small increase in adenosine levels, whereas ATV ϩ DIP caused a greater increase in adenosine levels (66.4 Ϯ 3.1 pg/l). ATV and DIP alone did not affect myocardial Ser473 phosphorylated-Akt and Ser1177 phosphorylated-eNOS levels, whereas ATV ϩ DIP significantly increased them. In conclusion, low-dose ATV and DIP had synergistic effects in reducing myocardial IS and activation of Akt and eNOS. This combination may have a potential benefit in augmenting the eNOS-mediated pleiotropic effects of statins. adenosine; Akt; infarct size; nitric oxide synthase SEVERAL EXPERIMENTAL STUDIES have shown that hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins), administered either before myocardial ischemia (3, 6, 10, 23, 24, 34 -36, 43, 44, 48, 50 -53) or immediately after reperfusion (5, 12, 50), reduce myocardial infarct size (IS). It has been shown that statins activate phosphatidylinositol-3-kinase (5,12,19,50) with subsequent activation of both Akt (5,11,12,18,19,27,30,35,38,50,53) and ecto-5-nucleotidase, which generates adenosine (9,35,46). Both Akt (5, 18, 27) and adenosine (15,29,39,40,47) activate endothelial nitric oxide synthase (eNOS). eNOS activation is essential for this protective effect, since nonspecific nitric oxide synthase inhibitors blunt the IS-limiting effect of statins (6, 51) and since statins do not reduce IS in eNOS Ϫ/Ϫ mice (5, 23, 52). Inhibition of ...