Zidovudine (AZT; 3-azido-3-deoxythymidine), a thymidine analog, has been a staple of highly active antiretroviral therapy. It is phosphorylated in the host to the triphosphate and functions by inhibiting the viral reverse transcriptase. However, long-term use of AZT is linked to various tissue toxicities, including cardiomyopathy. These toxicities are associated with mitochondrial DNA depletion, which is hypothesized to be caused by AZT triphosphate inhibition of mitochondrial DNA polymerase ␥. In previous work with isolated heart mitochondria, we demonstrated that AZT phosphorylation beyond the monophosphate was not detected and that AZT itself was a potent inhibitor of thymidine phosphorylation. This suggests an alternative hypothesis in which depletion of the TTP pool may limit mitochondrial DNA replication. The present work extends these studies to the whole cell by investigating the metabolism of thymidine and AZT in the intact isolated perfused rat heart. Zidovudine (AZT; 3Ј-azido-3Ј-deoxythymidine), a thymidine analog, is a member of the class of compounds called nucleoside analog reverse transcriptase inhibitors (NRTIs). Members of this class of drugs are phosphorylated by host cell enzymes to their triphosphates, which inhibit the human immunodeficiency virus (HIV) reverse transcriptase and/or act as chain terminators when they are incorporated into viral DNA, since these analogs cannot form 3Ј-phosphodiester bonds. AZT was the first drug approved by the Food and Drug Administration for the treatment of AIDS. In early monotherapy regimens, AZT was given alone at a dose of 1,200 mg per day (3). After some months of therapy, AZT was associated with a variety of common tissue toxicities that included myopathy, dilated cardiomyopathy, hepatotoxicity, various cytopenias, and lactic acidosis that were serious enough to result in the discontinuation of therapy in about 25 to 30% of patients (1, 5, 7, 9-11, 27, 29, 34, 37). In affected tissues, the mitochondria were abnormal, with reduced cristae and mitochondrial DNA (mtDNA) depletion (18,19,22). In present AIDS therapy, referred to as highly active antiretroviral therapy (HAART), AZT remains in common use but is given at a lower dose (600 mg per day) and in combination with a second NRTI and a viral protease inhibitor. As a result, the cardiovascular toxicity of the AZT used in HAART is now a rare event, and the main toxicities include lipodystrophy and cytopenias (2,12,28). AZT monotherapy is currently used to prevent the transmission of HIV from mothers to their babies prior to delivery and during the baby's first postnatal month (33). AZT is also a mainstay of HIV treatment in many resource-limited settings around the world (36). Understanding the mechanism of toxicity of AZT is of critical importance both in designing therapy to limit toxicity and in the rational design of less toxic therapeutic compounds.The phosphorylation of AZT is mediated by cellular enzymes of the thymidine salvage pathway, which convert thymidine to TTP. This pathway has two route...