Coronary artery disease (CAD) is the major cause of death in diabetics. Abnormal proliferation of coronary artery smooth muscle cells (CASMC) leads to intimal thickening in CAD. We examined signaling mechanisms involved in the mitogenic effect of ATP and insulin on CASMC. ATP and insulin individually stimulated DNA synthesis by 4- and 2-fold, respectively; however, they acted synergistically to stimulate an increase of 17-fold over basal. A similar synergistic stimulation of extracellular signal-regulated kinase (ERK) and mitogen-activated protein or ERK kinase activities was observed (ATP, 7-fold; insulin, 2-fold; and ATP + insulin, 16-fold over basal). However, the combination of ATP and insulin stimulated only an additive activation of Raf (ATP, 5-fold; insulin, <2-fold; and ATP + insulin, 8-fold over basal) and Ras (ATP, 5-fold; insulin, 2-fold; and ATP + insulin, 8-fold over basal). Thus convergence of ATP and insulin signals appears to be at the level of Ras and Raf. In addition, insulin stimulated activation of Akt (also known as protein kinase B) (10-fold over basal), whereas ATP had little effect. However, when ATP and insulin were added in combination, ATP dramatically reduced the insulin-stimulated Akt activation (2-fold above basal). Thus these results are consistent with ATP relieving an insulin-induced Akt-dependent inhibitory effect on the ERK signaling pathway, leading to synergistic stimulation of CASMC proliferation.