Global myocardial low flow ischemia results in an uniform suppression of norepinephrine (NE) overflow from the heart. We hypothesized that opening of neuronal ATP-sensitive potassium (K ATP ) channels as well as activation of the extraneuronal monoamine transporter (EMT) mediates attenuation of NE overflow during low flow ischemia. Isolated rat hearts were subjected to low coronary flow of 0.4 ml min Ϫ1 . Release of endogenous NE was induced by electrical field stimulation. EMT activity was measured as the transport rate of the substrate N- [methyl-3 H]4-phenylpyridinium ([ 3 H]MPP ϩ ). NE overflow decreased by 57 Ϯ 2% within 120 min of low flow. Five minutes of reperfusion at normal flow (8 ml min Ϫ1 ) restored NE overflow to baseline. K ATP channel blockade with glibenclamide as well as EMT blockade with corticosterone increased NE overflow 1.5-and 2-fold at 120 min of low flow, whereas neither drug affected NE overflow in the absence of flow reduction. At normal flow, K ATP channel opening with cromakalim suppressed NE overflow, both in the presence and absence of EMT blockade (14 Ϯ 4 and 9 Ϯ 1%). However, cromakalim had no effect on EMT activity as indicated by an unaffected [ 3 H]MPP ϩ overflow. In conclusion, activation of both K ATP channels and EMT mediate suppression of NE overflow during low flow ischemia. K ATP channels impair NE release directly at presynaptic nerve endings, whereas EMT increases NE elimination in a manner independent of K ATP channels.Cardiac sympathetic nerve activity in patients with acute myocardial infarction is critically dependent on the severity of coronary flow reduction and duration of energy deprivation. In myocardial tissue subjected to more than 10 min of stopflow, nonexocytotic norepinephrine (NE) release via the neuronal monoamine transporter (NET) prevails over exocytotic NE release, resulting in progressive interstitial transmitter accumulation (Schömig, 1990;Kurz et al., 1995;Imamura et al., 1996;Hatta et al., 1999;Levi and Smith, 2000;Oka et al., 2002;Sesti et al., 2003). In contrast, during prolonged periods of reduced coronary flow (low flow ischemia), exocytotic NE release decreases, resulting in a uniform suppression of NE overflow from the heart (Du and Riemersma, 1991). Because ischemia in vivo is neither absolute nor homogeneous, heterogeneity of NE release has substantial clinical implication, because it forms the substrate for malignant ventricular arrhythmias (Schömig et al., 1991). So far, the underlying metabolic alterations that affect sympathetic neurotransmission have been studied intensively in the setting of stopflow ischemia; however, less is known concerning the modulation of transmitter release during coronary low flow.It is well known that adenosine rapidly accumulates in the interstitial space in response to metabolic distress (Fredholm et al., 2001;Mubagwa and Flameng, 2001). Pharmacological blockade of presynaptic adenosine A 1 -receptors attenuates suppression of exocytotic NE release during low flow ischThis study was supported by ...