Previous studies have demonstrated that the local anesthetic bupivacaine selectively inhibits oxidative metabolism of fatty acids in isolated cardiac mitochondria. In the present investigation, we compare the development of bupivacaine cardiotoxicity during fatty acid and carbohydrate metabolism. Hearts from adult male Sprague-Dawley rats were excised and retrograde perfused with a solution containing fatty acid (oleate or octanoate) or carbohydrate substrates for cardiac metabolism. An infusion of bupivacaine was initiated and sustained until asystole, after which full cardiac recovery was allowed. During fatty acid metabolism, substantially lower bupivacaine doses induced both arrhythmia (60.4+/-11.5 microg oleate and 106.8+/-14.8 octanoate versus 153.4+/-21.4 carbohydrate; P<0.05) and asystole (121.0+/-30.1 microg and 171.5+/-20.2 versus 344.7+/-34.6; P<0.001). Dose-response analysis revealed significantly increased sensitivity to bupivacaine toxicity during fatty acid metabolism, indicated by lower V50 doses for both heart rate (70.6+/-5.6 microg oleate and 122.3+/-6.2 octanoate versus 152.6+/-8.6) and rate-pressure product (63.4+/-5.1 microg and 133.7+/-7.9 versus 165.1+/-12.2). Time to recovery following bupivacaine exposure was elevated in the fatty acid group (24.3+/-2.0 s versus 15.8+/-3.1; P<0.04). Fatty acid metabolism was shown to predispose the isolated heart to bupivacaine toxicity, confirming that the local anesthetic exerts specific effects on lipid processes in cardiomyocytes.