Therapy for ischemic heart disease has been directed traditionally at limiting cell necrosis. We determined by genome profiling whether ischemic myocardium can trigger a genetic program promoting cardiac cell survival, which would be a novel and potentially equally important mechanism of salvage. Although cardiac genomics is usually performed in rodents, we used a swine model of ischemia͞reperfusion followed by ventricular dysfunction (stunning), which more closely resembles clinical conditions. Gene expression profiles were compared by subtractive hybridization between ischemic and normal tissue of the same hearts. About one-third (23͞74) of the nuclear-encoded genes that were upregulated in ischemic myocardium participate in survival mechanisms (inhibition of apoptosis, cytoprotection, cell growth, and stimulation of translation). The specificity of this response was confirmed by Northern blot and quantitative PCR. Unexpectedly, this program also included genes not previously described in cardiomyocytes. Up-regulation of survival genes was more profound in subendocardium over subepicardium, reflecting that this response in stunned myocardium was proportional to the severity of the ischemic insult. Thus, in a swine model that recapitulates human heart disease, nonlethal ischemia activates a genomic program of cell survival that relates to the time course of myocardial stunning and differs transmurally in relation to ischemic stress, which induced the stunning. Understanding the genes up-regulated during myocardial stunning, including those not previously described in the heart, and developing strategies that activate this program may open new avenues for therapy in ischemic heart disease.apoptosis ͉ gene expression ͉ stunning O ne of the most important therapeutic targets in the treatment of cardiovascular disease has been the protection of ischemic myocardium from necrosis. This has been a major focus for basic and applied research over the past 30 years. More recently, mechanisms of programmed cardiac cell death (apoptosis) have also been studied extensively. Both necrosis and apoptosis result in the irreversible loss of contractile performance. An unexplored corollary to protection from cell death is the enhancement of cell survival. Our hypothesis is that myocardial ischemia elicits a genomic profile promoting cell survival, which would include the up-regulation of genes involved in prevention of apoptosis, cytoprotection, and cell growth. If a program of cell survival can be stimulated in the ischemic heart, it would represent a novel and important therapeutic strategy in the future.To address this hypothesis, we examined the genomic profile of ischemic myocardium in a model that is most relevant to clinical conditions, i.e., a swine model of transient ischemia.Although the majority of investigations on myocardial ischemia are conducted in rodent models, major differences exist between rodents and larger mammals (differences in heart rate, action potential, and calcium handling) (1, 2). We reasoned that th...