Coronary vasodilation is impaired in the postischemic heart with a loss of endothelial nitric oxide synthase (eNOS) activity, but the mechanisms underlying ischemia-induced eNOS dysfunction are not understood. For nitric oxide (NO) synthesis, eNOS requires the redox-sensitive cofactor tetrahydrobiopterin (BH 4); however, the role of BH 4 in ischemia-induced endothelial dysfunction remains unknown. Therefore, isolated rat hearts were subjected to varying durations of ischemia, and the alterations in NOS-dependent vasodilation were measured and correlated with assays of eNOS activity and cardiac BH 4 concentrations. Ischemia timedependently decreased cardiac BH 4 content with 85, 95, or 97% irreversible degradation after 30, 45, or 60 min of ischemia, respectively. Paralleling the decreases in BH 4, reductions of eNOS activity were seen of 58, 86, or 92%, and NOS-derived superoxide production was greatly increased. Addition of 10 M BH4 enhanced eNOS activity in nonischemic hearts and partially restored activity after ischemia. It also suppressed NOS-derived superoxide production. Impaired coronary flow during postischemic reperfusion was improved by BH 4 infusion. Thus, BH4 depletion contributes to postischemic eNOS dysfunction, and BH 4 treatment is effective in partial restoration of endothelium-dependent coronary flow. Supplementation of BH 4 may therefore be an important therapeutic approach to reverse endothelial dysfunction in postischemic tissues.ischemia reperfusion injury ͉ nitric oxide ͉ nitric oxide synthase uncoupling ͉ superoxide ͉ vascular function N itric oxide synthase (NOS) converts L-arginine and O 2 to nitric oxide (NO) and L-citrulline. This enzymatic process consumes NADPH and requires Ca 2ϩ /calmodulin, flavin adenine dinucleotide, flavin mononucleotide, and tetrahydrobiopterin (BH 4 ) as NOS cofactors. Endothelial NO synthase (eNOS) contributes to the regulation of vasomotor tone and blood pressure by producing NO that activates soluble guanylate cyclase in vascular smooth muscle, resulting in vasorelaxation (1-3).Endothelial dysfunction is a prognostic marker of cardiovascular disease (4). It has been suggested that limited availability of BH 4 contributes to eNOS dysfunction in hypercholesterolemia, diabetes, atherosclerosis, hypertension, and heart failure (5-9). It was also observed previously that eNOS function is impaired in ischemic hearts (10). In vivo coronary artery occlusion triggers endothelial dysfunction and decreased eNOSdependent vasoreactivity, although reactivity is preserved to exogenous NO (11,12). Endothelial-dependent coronary vasoreactivity is impaired in hearts subjected to periods of global ischemia and reperfusion (10). Endothelium-dependent vasodilators induce a relatively high increase in coronary flow in control hearts or in those made ischemic for short times, but longer periods of ischemia result in an abrupt decline in vasodilatory response.In addition to impairing eNOS-mediated NO formation, BH 4 depletion may have additional detrimental effects in postischem...