Abstract-Calcitonin gene-related peptide (CGRP) is a nonadrenergic/noncholinergic (NANC) peptide with vasodilatative/ inotropic action that may benefit the failing heart. However, precise mechanisms for its in vivo inotropic action remain unclear. To assess this, dogs with normal or failing (sustained tachypacing) hearts were instrumented for pressuredimension analysis. In control hearts, CGRP (20 pmol/kg per minute) enhanced cardiac contractility (eg, ϩ33Ϯ4.2% in end-systolic elastance) and lowered afterload (Ϫ14.2Ϯ2% in systemic resistance, both PϽ0.001). The inotropic response was markedly blunted by heart failure (ϩ6.5Ϯ2%; PϽ0.001 versus control), whereas arterial dilation remained unaltered (Ϫ19.3Ϯ5%). CGRP-positive inotropy was not attributable to reflex activation because similar changes were observed in the presence of a ganglionic blocker. However, it was fully prevented by the -receptor antagonist (timolol), identifying a dominant role of sympatho-stimulatory signaling. In control hearts, myocardial interstitial norepinephrine assessed by microdialysis almost doubled in response to CGRP infusion, whereas systemic plasma levels were unchanged. In addition, CGRP receptors were not observed in ventricular myocardium but were prominent in coronary arteries and the stellate ganglia. Ventricular myocytes isolated from normal and failing hearts displayed no inotropic response to CGRP, further supporting indirect sympatho-stimulation as the primary in vivo mechanism. In contrast, the peripheral vasodilatative capacity of CGRP was similar in femoral vascular rings from normal and failing hearts in dogs. Thus, CGRP-mediated positive inotropy is load-independent but indirect and attributable to myocardial sympathetic activation rather than receptor-coupled stimulation in canine hearts. This mechanism is suppressed in heart failure, so that afterload reduction accounts for CGRP-enhanced function in this setting. Key Words: calcitonin gene-related peptide Ⅲ sympathetic efferent fibers Ⅲ heart failure Ⅲ norepinephrine Ⅲ contractility C alcitonin gene-related peptide (CGRP) is a nonadrenergic/noncholinergic (NANC) peptide with potent vasodilator activity. 1-3 Its role as a counterbalance to vascular sympathetic nerve discharge is supported by the presence of hypertension in mice lacking CGRP. 4,5 Exogenous administration of CGRP to patients with congestive heart failure (CHF) increases cardiac output, 6 -8 although whether this reflects cardiac inotropy or peripheral vasodilation is unknown. CGRP receptor components (receptor activitymodifying protein 1 and calcitonin receptor-like receptor, RAMP1 and CRLR, respectively) are upregulated in failure models, 9 whereas circulating plasma levels are decreased, 10,11 and this might suggest a potential efficacy for exogenously administered CGRP. Recently, this notion received further attention with the discovery that the reduced form of nitric oxide (HNO/NO Ϫ ) is a potent cardiac stimulant in normal and failing hearts, which appears in part coupled to CGRP signaling. 11,1...