Atorvastatin (ATV) limits infarct size (IS) by activating Akt and ecto-5-nucleotidase, which generates adenosine. Activated Akt and adenosine activate endothelial nitric oxide synthase (eNOS). When given orally, high doses (10 mg/kg) are needed to achieve full protection. We determined whether dipyridamole (DIP), by preventing the reuptake of adenosine, has a synergistic effect with ATV in reducing myocardial IS. In this study, rats received 3-days of the following: water, ATV (2 mg.kg(-1).day(-1)), DIP (6 mg.kg(-1).day(-1)), or ATV + DIP. In addition, rats received 3-days of the following: aminophylline (Ami; 10 mg.kg(-1).day(-1)) or Ami + ATV + DIP. Rats underwent 30 min of myocardial ischemia followed by 4 h of reperfusion (IS protocol), or hearts were explanted for immunoblotting. As a result, IS in the controls was 34.0 +/- 2.8% of the area at risk. ATV (33.1 +/- 2.1%) and DIP (30.5 +/- 1.5%) did not affect IS, whereas ATV + DIP reduced IS (12.2 +/- 0.5%; P < 0.001 vs. each of the other groups). There was no difference in IS between the Ami alone (48.1 +/- 0.8%) and the Ami + ATV + DIP (45.8 +/- 2.9%) group (P = 0.422), suggesting that Ami completely blocked the protective effect. Myocardial adenosine level in the controls was 30.6 +/- 3.6 pg/microl. ATV (51.0 +/- 4.9 pg/microl) and DIP (51.5 +/- 6.8 pg/microl) caused a small increase in adenosine levels, whereas ATV + DIP caused a greater increase in adenosine levels (66.4 +/- 3.1 pg/microl). ATV and DIP alone did not affect myocardial Ser473 phosphorylated-Akt and Ser1177 phosphorylated-eNOS levels, whereas ATV + DIP significantly increased them. In conclusion, low-dose ATV and DIP had synergistic effects in reducing myocardial IS and activation of Akt and eNOS. This combination may have a potential benefit in augmenting the eNOS-mediated pleiotropic effects of statins.