T etrahydrobiopterin (BH 4 ) is an essential cofactor for the normal enzymatic function of endothelial NO synthase (eNOS) to produce NO, because it is involved in the catalytic process of L-arginine oxidation. Insufficient BH 4 availability impairs this process, and the free radical superoxide anion (O 2 ⅐Ϫ ) is released rather than NO, a condition termed "eNOS uncoupling." 1 BH 4 , eNOS, and NO levels physiologically increase in parallel, as seen in response to shear stress, the most important physiological stimulus for endothelial NO production. Shear stress increases BH 4 through a casein kinase 2-dependent phosphorylation of GTP cyclohydrolase-1, the enzyme catalyzing the first step in BH 4 synthesis. Blockade of GTP cyclohydrolase-1 by the specific inhibitor 2,4-diamino-6-hydroxypyrimidine (DAHP) results in eNOS uncoupling in endothelial cells exposed to shear stress. 2 In transgenic mice overexpressing eNOS, a large portion of the enzyme is uncoupled because of BH 4 deficiency, leading to excessive endothelial formation of O 2 ⅐Ϫ , which reacts rapidly to form peroxynitrite. 3 Because BH 4 is highly sensitive to oxidation by the particular aggressive reactive oxygen species (ROS) peroxynitrite, in most cardiovascular disease states, BH 4 is depleted. 4 Compelling evidence exists that eNOS uncoupling contributes to endothelial dysfunction in diabetes mellitus, atherosclerosis, and hypertension. NO is also an essential regulator of cardiac structure and function; however, only a few studies have investigated the role of BH 4 in this regard. Takimoto et al 5 revealed the importance of BH 4 depletion for eNOS uncoupling and subsequent left ventricular hypertrophy in mice subjected to pressure overload. Exogenous BH 4 was able to recouple eNOS and reverse pre-established advanced hypertrophy. 6 In addition, depletion of BH 4 and subsequent uncoupling of cardiac NO synthase appear to contribute to the development of diastolic dysfunction.In the present issue of Hypertension, Ceylan-Isik et al 7 report that eNOS uncoupling by BH 4 depletion through treatment with the GTP cyclohydrolase-1 inhibitor DAHP impaired myocyte and mitochondrial function in the heart (Figure). Their data clearly show that BH 4 depletion and subsequent O 2 ⅐Ϫ formation disrupt calcium handling and cardiomyocyte function. The data of Ceylan-Isik et al 7 further indicate a crosstalk between ROS produced from uncoupled eNOS and the mitochondria, leading to increased mitochondrial ROS production and mitochondrial dysfunction. The importance of mitochondrial ROS formation has also been highlighted recently in endothelial cells in response to angiotensin II, which induced mitochondrial dysfunction via protein kinase C-dependent activation of NADPH oxidase, and a crosstalk between mitochondrialand NADPH-oxidase-derived ROS was also found in nitroglycerin-triggered vascular dysfunction. 8,9 Cardiomyocyte-restricted overexpression of the ROS scavenger metallothionein prevented the DAHP-induced increase in O 2 ⅐Ϫ formation and preserved cardiomyocy...