The
pyridine nucleotides NAD(+) and
NADP(+) play a pivotal role in regulating intermediary metabolism in the heart. The intracellular
NAD(+)/
NADH ratio controls flux through various
dehydrogenase enzymes involved in both anaerobic and aerobic metabolism and also regulates posttranslational
protein modification. The intracellular
NADP(+)/
NADPH ratio controls flux through the pentose phosphate pathway (PPP) and the
polyol pathway, while also regulating
ion channel function and oxidative stress. Not only does the
NAD(+)/
NADH ratio regulate the rates of
ATP production, it can also modify energy substrate preference. For instance, in many forms of
heart disease a greater contribution from
fatty acids for oxidative energy metabolism increases
fatty acid β-oxidation-derived
NADH, which can activate
pyruvate dehydrogenase (
PDH) kinase isoforms that inhibit PDH and subsequent
glucose oxidation. As such, novel
therapies that overcome
fatty acid β-oxidation-induced inhibition of PDH improve cardiac efficiency and subsequent function during
ischemia/reperfusion and in
heart failure. Furthermore, recent studies have implicated a pivotal role for increased PPP-derived
NADPH in mediating oxidative stress observed in
heart failure. In this article, we review the multiple actions of
NAD(+)/
NADH and
NADP(+)/
NADPH in regulating intermediary metabolism in the heart. A better understanding of the roles of
NAD(+)/
NADH and
NADP(+)/
NADPH in cellular physiology and pathology could potentially be used to exploit
pyridine nucleotide modification in the treatment of a number of different forms of
heart disease.