We have previously shown that diabetes is associated with a decrease in Na(+)-H+ exchange activity in rat cardiac papillary muscle. The present work has been carried out in order to elucidate the factors responsible for such an alteration. Thus, we have studied the effects of pH0 and intracellular Ca2+ on Na(+)-H+ exchange in ventricular myocytes isolated from streptozotocin-induced diabetic rat hearts. pH1 was recorded using carboxy-seminaphthorhodafluor (SNARF-1). The NH4+ (10 mmol/L) prepulse method was used to induce an acid load in order to activate Na(+)-H+ exchange in HEPES-buffered Tyrode's solution. Whereas diabetes did not change intracellular buffering power, it significantly decreased acid efflux through Na(+)-H+ exchange (acid efflux, 4.32 +/- 0.4 [n = 32, normal cells] versus 2.5 +/- 0.2 [n = 43, diabetic cells] meq/L per minute at pHi 6.9; P < .02). Upon changes of pH0 (at a range of 8.0 to 6.8), acid efflux similarly varied in normal and diabetic cells, thus pointing to an unchanged pH0 sensitivity of Na(+)-H+ exchange. Buffering of intracellular Ca2+ by pretreatment of the cells with BAPTA-AM (25 mumol/L Ca2(+)-chelator) resulted in a decrease by approximately 58% of acid efflux in the diabetic group. This decrease was even more marked in normal cells (by approximately 74%). Interestingly, the pH1 dependence of the acid efflux carried by Na(+)-H+ exchange then became identical in both groups of cells, thus pointing to a role for intracellular Ca2+ in the diabetes-related alterations of the exchange. Inhibition of calmodulin (by 1.5 mumol/L calmidazolium) and of Ca2+/calmodulin-dependent protein kinase II (by 2 mumol/L 1-[N,O-bis(5-isoquinolinesulfonyl)-N-methyl-L-tyrosyl]-4-phenylpiperazin e [KN-62]) significantly slowed down pH1 recovery in both normal and diabetic cells. However, the effect of KN-62 was significantly lower in diabetic cells (efflux decreased by approximately 17%) compared with normal cells (decrease by 45%). In conclusion, these data, in light of recent observations showing a decreased [Ca2+]i associated with diabetes in isolated ventricular myocytes, suggest that changes in intracellular Ca2+ may play an important role in altering Na(+)-H+ exchange activity in diabetic ventricular myocytes. They also point to diabetes-related alterations in the Ca2+/calmodulin protein kinase II-dependent phosphorylation of Na(+)-H+ exchange.