. Erythropoietin affords additional cardioprotection to preconditioned hearts by enhanced phosphorylation of glycogen synthase kinase-3. Am J Physiol Heart Circ Physiol 291: H748 -H755, 2006. First published March 24, 2006 doi:10.1152/ajpheart.00837.2005.-The aim of this study was to determine whether erythropoietin (EPO) affords additional cardioprotection to the preconditioned myocardium by enhanced phosphorylation of Akt, STAT3, or glycogen synthase kinase-3 (GSK-3). Preconditioning (PC) with 5-min ischemia/5-min reperfusion and EPO (5,000 U/kg iv) reduced infarct size (as % of area at risk, %IS/AR) after 20-min ischemia in rat hearts in situ from 56.5 Ϯ 1.8% to 25.2 Ϯ 2.1% and to 36.2 Ϯ 2.8%, respectively. PC-induced protection was significantly inhibited by a protein kinase C inhibitor, chelerythrine (5 mg/kg), and slightly blunted by a phosphatidylinositol-3-kinase inhibitor, wortmannin (15 g/kg). The opposite pattern of inhibition was observed for EPO-induced protection. The combination of PC and EPO further reduced %IS/AR to 8.9 Ϯ 1.9%, and this protection was inhibited by chelerythrine and wortmannin. The additive effects of PC and EPO on infarct size were mirrored by their effects on the level of phosphorylated GSK-3 at 5 min after reperfusion but not their effects on the level of phospho-Akt or phospho-STAT3. To mimic phosphorylation-induced inhibition of GSK-3 activity, SB-216763 (SB), a GSK-3 inhibitor, was administered before ischemia or 5 min before reperfusion. Infarct size was significantly reduced by preischemic injection (%IS/AR ϭ 40.4 Ϯ 2.2% by 0.6 mg/kg SB and 34.0 Ϯ 1.8% by 1.2 mg/kg SB) and also by prereperfusion injection (%IS/AR ϭ 32.0 Ϯ 2.0% by 1.2 mg/kg SB). These results suggest that EPO and PC afford additive infarct size-limiting effects by additive phosphorylation of GSK-3 at the time of reperfusion by Akt-dependent and -independent mechanisms. infarct size; phosphatidylinositol-3-kinase; protein kinase C; Akt HUMAN RECOMBINANT ERYTHROPOIETIN (EPO) has been used for decades as a standard therapy for renal anemia. However, recent studies have shown that EPO has potent cell-protective effects in various tissues, including myocardium, in addition to its effect on erythropoiesis (5-7, 12, 16, 25, 26, 33-35, 43). The presence of the EPO receptor in cardiomyocytes has been indicated in , and administration of EPO before or at the time of ischemia has been shown to reduce necrosis, apoptosis, and ventricular dysfunction after ischemia-reperfusion (6,7,12,16,25,(33)(34)(35)43). These features of EPO-induced cardioprotection are similar to those of ischemic preconditioning (PC). Furthermore, it is interesting to note that there are overlaps in signaling pathways provoked by activated EPO receptors and PC: phosphatidylinositol-3-kinase (PI3K)-Akt pathway, ERK pathway, and STAT-mediated pathway (1, 3, 13, 16 -18, 21, 30, 34 -39, 43). However, it is not clear which signaling molecule primarily determines the level of cardioprotection against infarction. It is also unclear whether sign...