Phenamil, an amiloride derivative, is a potent inhibitor of epithelial type sodium channels and a relaxant of smooth muscle. In canine cardiac ventricular trabeculae, which do not express epithelial type sodium channels, phenamil produces positive inotropy and prolongs twitch duration. Sarcoplasmic reticulum does not appear to be essential for phenamil-induced inotropy, because cyclopiazonic acid and ryanodine do not abolish this effect. Furthermore, in tissues made to contract biphasically with 90 to 98% substitution of calcium with strontium, phenamil enhanced the second phase of the contraction which is transsarcolemmal-calcium dependent. Phenamil did not alkalinize or acidify the cytosol (measured with 2',7'-bis(carboxyethyl)-5,6-carboxyfluorescein, BCECF) during the induction of positive inotropy, therefore the sodium-hydrogen exchange is not affected. Sodium-calcium exchange, as assessed by twin rapid cooling contractures, was not inhibited by phenamil. Direct inhibition of this exchanger is therefore not necessary for the inotropic action of phenamil. Phenamil did not inhibit the sodium pump in smooth muscle. Unlike ouabagenin, it significantly prolonged the action potential duration at 90% repolarization. We have demonstrated recently that prolongation of cardiac action potential duration with phenamil is due to inhibition of the inwardly rectifying potassium current without any direct effect on cardiac calcium channels. The resulting delay in repolarization of the terminal part of the action potential reduces the driving force for the forward mode of sodium-calcium exchange. This indirectly reduces the activity of the sodium-calcium exchanger and slows the extrusion of calcium from the cell at the end of the action potential leading to a gradual development of positive inotropy.