WHEN NITRIC OXIDE (NO) donors were first administered to isolated, normal cardiomyocytes, a negative, cGMP-dependent inotropic effect was observed, whereas inhibitors of NO synthases (NOS) had no effect. Further studies then demonstrated a biphasic contractile response to exogenous NO and cGMP, explained by dose-dependent inhibition or activation of phosphodiesterases modulating cAMP. Also, exogenous NO can, via cGMP, activation of protein kinase G, and phosphorylation of troponin I, decrease myofilamental calcium responsiveness and exert cGMP-independent positive inotropic effects by nitrosylation. These in part contradictory findings are not surprising given the multiple mechanisms (via cGMP, nitrosylation, antioxidation), sites of production (cardiomyocytes, endothelial cells, nerve endings), and targets (mitochondrial respiration, glucose transport, cAMP turnover, L-type calcium channels, sarco(endo)plasmic reticulum Ca 2ϩ -ATPase, ryanodine receptor, myofilaments) of myocardial NO signaling known to date (11).Large animal studies demonstrated that there is a net positive inotropic effect of constitutive myocardial NO synthesis during normoperfusion and ischemia (6) and that basal NO release supports myocardial efficiency, i.e., the amount of myocardial work produced at a given level of oxygen consumption, during normoperfusion, ischemia (6), exercise (2), and pacing-induced heart failure (15). This was ascribed to a counterbalance of xanthine oxidase-derived oxygen radical production by NO (15). Importantly, heart failure represents a NO-deficient state by decreased myocardial production (14) and/or increased oxidative inactivation (1) of NO, whereas in the exercised heart, as the conceptual opposite of the failing myocardium, NO production and antioxidative capacity are increased (4,19). In line with that, upregulation of NO synthesis by statins attenuated heart failure after myocardial infarction in rats (13) or during tachycardic pacing in dogs (20).Knockout models of the constitutive NOS isoforms in mice showed that both endothelial NOS (eNOS) (17) and neuronal NOS (nNOS) (3, 16) support cardiac function after myocardial infarction and that the presence of eNOS is a prerequisite for the salutary effect of statins (9) and angiotensin-converting enzyme antagonism (10). In detail (11), eNOS is subcellularly localized to caveolae in the sarcolemma controlling ß-adrenergic signaling transduction at the level of cAMP and L-type calcium channels. nNOS colocalizes with the cardiac sarcoplasmic reticulum, limiting calcium cycling in the basal state but facilitating it during adrenergic and frequency (8) stimulation, although the precise mechanisms are still under debate. Taken together, constitutive myocardial NO synthesis is protective, sensitive to oxidative stress, and modulates myocardial function at multiple sites.It has been known for some time that in the vasculature, vasodilation by NO does not only depend on the presence of eNOS and is limited by oxidative inactivation of NO but also can be increased by...