Hypertension. 2001;37:767-773
(Hypertension. 2001;37:767.)
© 2001 American Heart Association, Inc.
Workshop: Hypertension and Cardiovascular Risk Factors
Role of the Angiotensin IINitric Oxide Interaction
Leopoldo Raij
From the Department of Veterans Affairs Medical Center, Minneapolis, Minn
Correspondence to Leopoldo Raij, MD, Chief, Nephrology/Hypertension Section (111J), Department of Veterans Affairs Medical Center, One Veterans Dr, Minneapolis, MN 55417. E-mail raijx001{at}tc.umn.edu
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Abstract
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Vascular
upregulation of nitric oxide (NO) is an adaptive response
to increased
blood pressure that may help in the prevention
of end-organ damage.
Differences in cardiovascular and renal
morbidity and
mortality in hypertensive patients may result,
at least in part, from
individual variations in endothelial
function in
response to the hemodynamic workload of hypertension.
A
functional feedback balance exists between both angiotensin
(Ang) II and NO under normal conditions. The NO-Ang II imbalance
may
not explain all the vascular pathophysiology of hypertension,
but it
certainly appears to be an important component. In hypertension,
salt
sensitivity, whether primary (ie, certain populations
in the United
States and Japan) or secondary (ie, aging, type
II diabetes), appears
to be a marker of increased cardiovascular
and renal
risk that is often linked to a decreased bioactivity
of NO. In diabetes
and atherosclerosis, NO-dependent vascular
relaxation
is impaired and can be restored by decreasing the
synthesis and/or
blocking the action of Ang II. An understanding
of the relations
between hypertension, cardiovascular risk
factors,
end-organ damage, and the NO-Ang II axis leads one
to believe that the
combination of therapeutic agents capable
of reinstating the
homeostatic balance of these vasoactive
molecules within the vessel
wall would be most effective in
preventing or arresting end-organ
disease.
Key Words: endothelium angiotensin II nitric oxide stress
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Introduction
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The role of the
renin-angiotensin (Ang) II system, particularly
of Ang II,
holds high interest in the areas of cardiovascular
and
renal physiology and pathology. Of most interest, after
the discovery
of the beneficial effects of Ang IIconverting
enzyme (ACE)
inhibitors in hypertension and cardiovascular
and renal
disease, are Ang IIs nonhemodynamic
effects
1 2 rather
than its better-known hemodynamic effect as a
vasopeptide.
The
L-arginine/nitric oxide
(NO) pathway, particularly NO
as an endothelial-derived
relaxing factor, has also been an
area of keen
interest.
3 4 5 6
The interactions of and balance
between Ang II and NO are of key
importance in cardiovascular
and renal injury and are
the focus of this review. Indeed,
the presence or the relative
bioavailability of either one
can make it either injurious or
protective of target organs
(Figure 1
).

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Figure 1. Schematic representation of the pathophysiology of the interaction between Ang II and NO (modified from Reference 72).
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Research shows general agreement that functionally complete
local renin-angiotensin systems are operative within
organs/tissues.7 8 9
The systems act in both autocrine and paracrine
fashion,7 8
potentially accounting for the local actions of Ang II and NO;
angiotensin II and NO interact at the level of the
endothelium, which is where they undergo the final step
of synthesis as well as at the level of vascular smooth muscle cells,
mesangial cells, and matrix. The
endothelial cells contain ACE, which converts Ang I to
Ang II. NO has been shown to downregulate the synthesis of
ACE10 in the
endothelium, as well as Ang II type 1 receptors
(AT1) in vascular smooth muscle cells, thus
having the potential to decrease Ang II production and
action.11 12
NO is synthesized in the endothelium by a
constitutive endothelial NO synthetase (eNOS), part of
the NOS isoforms
family.3 5 eNOS is
calcium- and
calmodulin-dependent3 5
and can be activated by neurohumoral substances such as
acetylcholine, substance P, bradykinin, and adenosine
diphosphate as well as by such mechanical stimuli physical forces as
shear stress and cyclic strain. Under physiological
conditions such as exercise, eNOS is upregulated, leading to
vasodilation and increased blood flow to the
organs.13 14
NO, which has a short half-life, is rapidly
inactivated either by superoxide anions
(O2-) or by binding
to hemoglobin5 after release.
Thus, increased levels of
O2-, as they occur
in pathological conditions, may dramatically shorten the bioactivity of
NO and/or transform it into a toxic
metabolite.15 NO actions can
be inhibited by NOS inhibitors, whereas Ang II, because it
combines with receptors to exert its actions, can be inhibited by Ang
II receptor blockers.1 ACE
inhibitors not only decrease Ang II synthesis but prevent
the degradation of bradykinin, one of the most important
physiological molecules involved in the release of
NO.16 17 18
The main subtypes of Ang II receptors are
AT1 and
AT2.19 20
AT1 mediates the vasoconstrictor effect of Ang
II and mediates the Ang IIinduced growth in
cardiovascular and renal
tissue.17 NO can downregulate
AT1 receptors in vascular
tissue11 and the adrenal
gland12 and mitigate the
actions of Ang II.21
AT2 actions are less well understood, although
it is known that in adult animals, they may upregulate in response to
injury. AT2 receptors have been associated with
the synthesis and/or the release of both prostaglandins and
NO.22 23
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Interaction of Ang II and NO in the Regulation
of Vascular Tone
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Hypertension involves 3 major factors: abnormal
vascular tone,
abnormalities in volume and salt regulation, and vessel
wall
remodeling. Both NO and Ang II are important players in these
pathogenetic mechanisms.
Ang II is a potent vasoconstrictor with growth-promoting
properties. In the kidney, this vasoconstrictor effect is more
pronounced in the efferent than the afferent glomerular
arterioles and leads to an increase in glomerular capillary
pressure.24 25 26
Various factors may cause the differential intrarenal vasoconstrictor
response to Ang II: smaller efferent arteriolar
diameter,27
maintenance of an afferent vasodilatory tone by
NO,24 28 29
and activation of AT2 receptors in the afferent
arterioles, resulting in vasodilation through the cytochrome
P-450dependent pathway.30
NO is a vasodilator with antigrowth and antithrombogenic
effects that plays a role in maintaining vascular integrity and
preventing end-organ damage. Its vasodilatory effect is mainly on the
afferent arteriole in the cortical nephrons, but it can affect both
afferent and efferent arterioles in juxtamedullary
nephrons.31 32
AT1 receptor blockade can abolish the
vasoconstrictor effect of NOS inhibition on cortical blood flow but has
minor effects on medullary blood
flow,33 which suggests that
NO may be a more effective modulator of Ang IImediated
vasoconstriction in cortical than in medullary
nephrons.33 NO
production is continuous, imparting a constant vasodilatory
effect24 and helping maintain
resting vascular tone and normal blood pressure. Ang II
production is not as constant, however, and its main
physiological role is to increase vascular tone in
response to decreased blood volume and/or flow. Its contribution to the
steady state of vascular tone in the stable, homeostatic individual is
unclear.24 34
The kidneys inability to adequately excrete salt is
considered to be a major pathogenetic component in hypertension. NO may
play a role in salt excretion by directly decreasing tubular sodium
reabsorption or indirectly through modulation of renal medullary blood
flow.15 34 35 36
Ang II, however, has antinatriuretic properties
because of its effects on the renal tubules and renal blood flow plus
the feedback regulation of renin release from the macula
densa.25 34
In people with essential hypertension, impairment of
NO-mediated endothelium-dependent relaxation
occurs.37 38 At
times, the impairment precedes the hypertension, which has been found
to occur in some normotensive
blacks39 and normotensive
offspring of hypertensives.40
Many normotensive offspring of patients with premature myocardial
infarction manifest abnormal endothelium-dependent
relaxation and increased intima-media thickness in the carotid
arteries.41
Development of hypertension has been documented in animals
with long-term blockade of NO synthesis or knockout of the NOS gene,
whereas hypotension has been found in mice that overexpress the NOS
gene.42 43 Local
administration of the NOS inhibitor
NG-monomethyl-L-arginine
into the brachial artery of humans produces a dose-dependent fall in
forearm flow,44 which
suggests that NO also participates in the regulation of vascular tone
in humans.
The synthesis or release of such vasoactive agents as
endothelin-1 (ET-1) and Ang II are likely modulated by the effects of
NO, as shown by increasing
evidence.45 46
Interaction between NO and ET-1 appears to be more important under
pathological than physiological conditions, because
ET-1 synthesis is upregulated by Ang II and downregulated by
NO.
The development and/or maintenance of both
hypertension and the abnormal vascular remodeling that occurs in such
circumstances as atherosclerosis and after myocardial
injury47 48 is
probably due in part to a loss of NO and, more important, to an
imbalance among Ang II, NO, and
O2-
production.45 47 49
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NO-Ang II in Cardiovascular
and Renal Injury
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Vascular remodeling is a dynamic process of adaptation
of the
vascular beds to hypertension caused increases in
hemodynamic
workload.
47 All cellular
components participate in the process.
In the heart, remodeling results
in myocyte hypertrophy and
increased extracellular
matrix;
47 in vessels, it is
characterized
by an increased media/lumen ratio; and in the glomerulus,
it
results in an increase in size and number of mesangial
cells
and/or the amount of mesangial
matrix.
45 50 51
These adaptive
changes end up being maladaptive in many patients,
leading
to left ventricular hypertrophy (LVH)
and heart failure, ischemia
of vascular territories, and renal
failure.
52
Ang II affects growth-related processes directly as well as
indirectly by means of synthesis of growth factors such as
platelet-derived growth factor and transforming growth factor-ß
(TGF-ß).47 51 In
addition, it promotes synthesis of ET-1, which is in itself a
vasoconstrictor and facilitator of vascular smooth muscle cell and
mesangial cell
growth.46 53 NO,
however, downregulates TGF-ß and has been shown to be a
powerful endogenous inhibitor of growth-related
responses in vascular smooth muscle cells, mesangial cells,
and extracellular matrix.26
In addition, platelet aggregation and the expression of adhesion
molecules are inhibited by
NO.6 26 These
actions of NO have been confirmed in in vivo studies in mice that are
genetically deficient in endothelial NOS and subjected
to hemodynamic
injury.48 54 55
Finally, recent studies have shown that NO downregulates synthesis of
both ACE10 and
AT1
receptors11 and inhibits the
synthesis of ET-1.56
Experimentally, inhibition of renal NO synthesis results in increased
intrarenal synthesis of Ang
II.57 Clinically, blockade of
the AT1 receptor normalizes NO-mediated vascular
relaxations in patients with
atherosclerosis.58
A new mechanism involved in the countervailing interaction
between NO and Ang II was elucidated recently, namely the activation of
NADH/NADPH oxidases that lead to the production of
O2-. Ang IIdriven
O2-
production has been identified in vascular smooth muscle
cells,19
mesangial
cells,59 and aortic
adventitial fibroblasts.60
Extracellularly, O2-
inactivates NO; whereas intracellularly, it
activates MAP kinases and leads to vascular smooth muscle and
mesangial cell
hypertrophy.15 19 59
The pathogenesis of hypertensive end-organ injury is
affected by both an NO deficit and an Ang II
increase.19 Most studies
suggest that end-organ damage in hypertension is diffuse and affects
organs to different degrees within individual
patients.52 The
endothelial response to hypertension is to organize a
complex local environment that includes upregulation of NO and
inhibition of the effects of Ang II. It is through this
endothelial function that end organs may be spared from
the effects of
hypertension.13 15 61 62
In experimental models of hypertension, spontaneously
hypertensive rats (SHR) show increased production of renal,
aortic, and cardiac NO, whereas Dahl salt-sensitive rats (DS) show
decreased NO production. DS show 5 times more proteinuria than
SHR and 9 times more glomerular injury at similar blood
pressure;62 63 they
also show more aortic hypertrophy and
LVH.62 These results suggest
that in response to hypertension, DS have a paradoxical decrease in NO
production that ultimately promotes
cardiovascular and renal
injury.62
It is reasonable to conclude that the cause of end-organ
dysfunction in hypertensive individuals is multifactorial and that both
Ang II and NO appear to play a pivotal but not exclusive
role.26 Decreased vascular NO
bioactivity that results from endothelial dysfunction
may promote abnormal end-organ vascular remodeling through either
absolute or relative changes in the level of activity of NO compared
with Ang
II.26 48
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NO-Ang II in Diabetes and in Insulin
Resistance
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Hypertensive patients as well as their first-degree
relatives
commonly show abnormalities of insulin, glucose, and
lipoprotein
metabolism.
64 In
many patients, insulin resistance, manifested
by a defect in the
ability of insulin to stimulate the metabolism
of glucose
by muscle and its storage as glycogen, is the hallmark
of this
metabolic syndrome. It is important to realize, however,
that although insulin resistance and
hyperinsulinemia are
common in hypertensive
patients, hypertension does not occur
in all patients with
hyperinsulinemia.
Insulin resistance and hyperinsulinemia
are more severe and more closely associated with hypertension in obese
than in nonobese patients.64
The prevalence of microalbuminuria is increased in
hypertensive patients with insulin resistance;
microalbuminuria as well as insulin resistance and
hyperinsulinemia have been associated with an
increased risk for atherosclerotic cardiovascular
disease.64
Steinberg et al65
demonstrated that insulin enhances the release of
endothelium-derived NO, and Baron et
al66 demonstrated that
insulin-resistant states including obesity, hypertension, and
type 2 diabetes mellitus exhibit blunted insulin-mediated vasodilation
and impaired endothelium-dependent vasodilation. These
investigators suggested that endothelial dysfunction is
an integral component of the syndrome of insulin resistance,
independent of hyperglycemia; they further suggested that the
endothelial dysfunction worsens insulin resistance and
predisposes individuals to macrovascular disease.
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NO-Ang II in Salt Sensitivity
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Bigazzi et
al
64 reported that
salt-sensitive patients with
essential hypertension are more likely to
manifest hyperinsulinemia,
hyperlipidemia, and microalbuminuria. In
this context, therefore,
salt sensitivity can be a marker for increased
cardiovascular
risk in patients with essential
hypertension.
Findings by Reaven et
al67 demonstrated remarkable
similarity between DS and salt-sensitive humans: compared with control
Sprague-Dawley rats, DS manifested a defect in insulin-stimulated
glucose uptake by isolated adipocytes. These metabolic
changes do not depend on DS eating a high-salt diet and do not vary as
a function of salt intake, which suggests that in the rats, as in
salt-sensitive humans,68
susceptibility to the development of endothelial
dysfunction and end-organ disease is part of the cluster of
abnormalities that predispose to
hypertension.69 Similar to
the observations in SHR,62
groups of patients with severe hypertension have been identified who
are not salt sensitive, have minimal LVH, no renal injury, and normal
endothelial
function.70
The association between microalbuminuria and the
progression of diabetic nephropathy has been clearly
established in patients with type 1 diabetes mellitus. However, recent
studies from several laboratories have established that
microalbuminuria is a marker of
cardiovascular morbidity in nondiabetic patients with
essential hypertension as well as in patients with type 2 diabetes
mellitus.71 Salt-sensitive
hypertensive patients have a greater incidence of
microalbuminuria;64 71 72
this has led investigators to suggest that microalbuminuria
may be a useful predictor of salt sensitivity and renal
hemodynamic abnormalities in patients with essential
hypertension.73 In
atherosclerosis, there is upregulation of vascular ACE
and AT1 receptors and decreased bioactivity of
NO. Clinically, AT1 receptor blockade normalizes
endothelium-dependent relaxations mediated by NO in
patients with
atherosclerosis.58
Statins have been shown to upregulate eNOS and decrease ET-1
synthesis.74
The association between endothelial
dysfunction, dysregulation of NOS activity, end-organ damage, and salt
sensitivity in hypertension is intriguing. Salt-sensitive hypertension
has been linked to a decrease in renal NO production,
inappropriate activation of the renin-angiotensin system,
or both.71 72
However, a causality relationship between salt sensitivity and NO
deficiency has not yet been clearly
identified.71
Heimann et al75
reported a higher incidence of left ventricular mass in
salt-sensitive hypertensive patients than in salt-resistant
hypertensive patients. More recently, in a study of 350 Japanese
patients with essential hypertension, Morimoto et
al76 demonstrated that
patients who were salt-sensitive more often had LVH and experienced
more cardiovascular events than the nonsalt-sensitive
hypertensive patients.
Several studies have shown an association between
endothelial function and vascular compliance and
suggest that endothelium dependent vascular relaxation (EDR)
mediated by NO contribute to the maintenance of vascular
compliance.77 In the aorta, a
reduction in vascular compliance promotes LVH because of increased
impedance to left ventricular
function.77 It has been
reported that salt-sensitive hypertensive patients manifest impaired
EDRs that are mediated by
NO.68 It has been suggested
that impaired vascular relaxation precedes hypertension in some
populations of blacks and that it further deteriorates with age and
after the development of
hypertension.78 Similar
observations have been made in Italy in children of
hypertensives.40
Impaired NOS activity in salt-sensitive experimental models
of hypertension has been
demonstrated.62 79
In hypertensive humans, independent of the effects of salt on blood
pressure, salt sensitivity may be a marker for susceptibility to
cardiovascular and renovascular
injury.64 72 It is
interesting to note that aging as well as diabetes are characterized by
increased prevalence of hypertension, salt sensitivity, and decreased
EDR-mediated by
NO.68 80 Hence, it
is tempting to speculate that in hypertension, salt sensitivity,
whether primary (ie, certain populations in the United States and
Japan)76 78 or
secondary (ie, aging, type II diabetes
mellitus),81 is a marker of
increased cardiovascular and renal risk that is linked
to a decreased bioactivity of NO
(Figure 2).

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Figure 2. Schematic representation of the relationship between hypertension, end-organ injury, salt sensitivity, and the NO-Ang II interaction (based on References 13, 26, 3741, 45, 48, 57, 64, 66, 70, 72, 81).
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NO-Ang II and the Kidney
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NO synthesis inhibition and Ang II stimulation are
quite similar
in terms of regulation of vascular tone and vascular
pathology.
It remains unclear the extent to which the vasoconstrictor
response
to NO blockade results from withdrawal of an active NO
vasodilatory
stimulus and how closely related this response is to
amplification
of underlying vasoconstrictor
systems.
10 82 83
Ang II blockade has not been found to have an effect on the
renovasoconstrictor response to acute NO inhibition in the conscious
unstressed
rat.84 85 In the
conscious rat and dog, however, infusion of Ang II given alone at a
dose that has little effect on renovascular resistance causes massive
renal vasoconstriction when the NO system is also acutely
inhibited.86
Thus, the renal vasoconstriction produced by acute NO
blockade does not require the participation of the Ang II system.
However, when Ang II levels are sufficiently high to affect
renovascular tone, NO is important in maintaining renal
perfusion.6 24
Intrarenal inhibition of NO causes an increase in afferent arteriolar
resistance and a decrease in the ultrafiltration
coefficient.87 This is, at
least in part, the result of the unopposed action of Ang
II.32 88 However,
the glomerular capillary pressure does not change unless
the systemic administration of NOS inhibitors results in a
significant increase in systemic arterial blood
pressure.32 88
Selective inhibition of NO synthesis in renal medullary interstitium
decreases papillary blood flow and diminishes urinary sodium excretion
without altering GFR or systemic blood
pressure.89 90
The situation with chronic NOS inhibition is different.
Hypertension caused by chronic inhibition is not entirely
NO-dependent.91 Moreover, the
rescue administration of
L-arginine had no effect in
a chronic model of hypertension in which NO had been inhibited for 5 to
6 weeks.91 This chronic NO
inhibition is accompanied by increased intrarenal Ang II synthesis and
upregulation of TGF-ß and results in glomerular and
tubulointerstitial
injury,62 as well as
coronary vascular remodeling, LVH, and
hypertension.6 61
Studies that compared endothelial NOS knockout mice to
wild mice showed that in the former mice, a more marked increase in
vessel wall thickness develops because of vascular smooth muscle
hyperplasia in response to hemodynamically mediated
vascular injury.48
Pulmonary artery hypertrophy in response to
hypoxia is also more marked in these
mice.54
Hayakawa and
Raij62 suggested that
deficiency in NO synthesis conditions the severity of vascular and
ventricular hypertrophy in response to
hemodynamic changes in genetic models of hypertension.
This led to the conclusion that although acute inhibition of NO leads
to hypertension, once the chronic phase is established, NO deficiency
is not the sole mechanism for the maintenance of hypertension
and target organ injury. It has also been suggested that in chronic
hypertension, Ang II and ET-1 play an important role in the
maintenance of hypertension and cardiorenal damage when NO
bioactivity is
deficient.46 57 92
In chronic hypertensive models, the administration of ACE
inhibitors as well as AT1 blockers
reduces the severity of hypertension and ameliorates cardiorenal
injury.92 93
AT1 blockers can largely attenuate renal pressor
response to NOS inhibition but not to the same degree as the systemic
pressor response, suggesting that Ang II may not have a major
interaction with NO in the maintenance of total
peripheral resistance and therefore systemic blood
pressure. However, renal vasoconstriction in response to NOS inhibition
is largely mediated by the unbridled influence of
endogenous Ang II, especially when Ang II is
increased.24
In summary, it has become clear that the balance between NO
and Ang II, rather than the absolute concentration of either, is what
determines their effect on cardiovascular and renal
physiology and pathophysiology
(Figure 1). The reasons for the imbalances between the
substances are often unclear. An understanding of the relations between
hypertension, end-organ damage, and the NO-Ang II axis leads one to
believe that available therapeutic strategies capable of restoring the
homeostatic balance of these vasoactive agents within the vessel wall
would be effective in preventing or arresting end-organ disease.
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Acknowledgments
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This work was supported by research
funds from the Veterans
Affairs Administration. The author would like
to thank Martha
Heiberg and Barb Devereaux for secretarial
assistance.
Received October 24, 2000;
first decision November 30, 2000;
accepted December 18, 2000.
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