Vasculoprotective and Cardioprotective Mechanisms of Angiotensin‐Converting Enzyme Inhibition: The Homeostatic Balance Between Angiotensin II and Nitric Oxide

Abstract

The ability of the vasculature to modify its geometry in accordance with conditions of its microenvironment—the process of vascular remodeling—is an important pathobiologic process common to vascular disorders such as atherosclerosis, restenosis after angioplasty, and hypertension. Vascular remodeling characterizes the natural history of atherosclerosis, contributes to increased vascular resistance, and may contribute to the clinical complications of hypertension. A growing body of evidence indicates that locally generated vasoactive substances such as angiotensin II and nitric oxide are important determinants of the natural history of vascular disease. In particular, angiotensin II may promote vascular lesion formation by increasing vascular cell population via increased cell growth and decreased programmed cell death, and it may also alter extracellular matrix composition. Thus, angiotensin II is a pleiotropic local mediator capable of modulating cell growth, programmed cell death, migration of vascular smooth muscle cells, and extracellular matrix modulation, all of which are biologic mechanisms of vascular remodeling and intimal formation. This is proposed to occur via a local tissue angiotensin system. Angiotensin II may also promote chronic hypertension by modulating the vascular redox state and promoting the catabolism of the endothelium‐derived nitric oxide, an endogenous inhibitory vasodilator. Because angiotensin‐converting enzyme (ACE) is strategically positioned to influence the activity of at least three local vasoactive systems—angiotensin II, nitric oxide, and bradykinin—blocking ACE with ACE inhibition may have profound effects on ventricular and vascular structure and function, and have particular efficacy in preventing the morbidity and mortality of vascular diseases such as hypertension and atherosclerosis.