Abstract-Tetrahydrobiopterin (BH 4 ) is an essential cofactor for the aromatic amino acid hydroxylases, which are essential in the formation of neurotransmitters, and for nitric oxide synthase. It is presently used clinically to treat some forms of phenylketonuria (PKU) that can be ameliorated by BH 4 supplementation. Recent evidence supports potential cardiovascular benefits from BH 4 replacement for the treatment of hypertension, ischemia-reperfusion injury, and cardiac hypertrophy with chamber remodeling. Such disorders exhibit BH 4 depletion because of its oxidation and/or reduced synthesis, which can result in functional uncoupling of nitric oxide synthase (NOS Key Words: tetrahydrobiopterin Ⅲ nitric oxide synthase Ⅲ atherosclerosis Ⅲ inflammation I n 1963, a naturally occurring coenzyme for phenylalanine hydroxylase (PAH) was discovered to be the unconjugated pterin 5,6,7,8-tetrahydrobiopterin (BH 4 ). 1 BH 4 was subsequently found to be an essential cofactor for several other aromatic amino acid hydroxylases (tyrosine 2 and tryptophane 3 ) involved with neurotransmitter biosynthesis, glyceryl-ether mono-oxygenase, and nitric oxide synthase (NOS). To be functional, BH 4 must be in its fully reduced form, and depletion and/or BH 4 oxidation to BH 3 and BH 2 reduces its activity. For the cardiovascular system, the role of BH 4 in NOS activity is particularly relevant. Reduced BH 4 was first shown to contribute to vascular pathophysiology and hypertension, whereas more recent studies have found important roles in cardiac hypertrophy and remodeling, and ischemia/reperfusion physiology. Development of genetic mouse models that modulate BH 4 synthesis have greatly advanced understanding of its role to normal NOS and vascular function. Here we briefly review the pharmacology, physiology, and therapeutic potential of BH 4 .
BH 4 BiosynthesisBH 4 is formed by either a de novo or salvage pathway (Figure 2). De novo synthesis starts with guanidine triphosphate cyclohydrolase (GTPCH) in a magnesium, zinc, and NADPHdependent reaction, and continues through 2 intermediates (7,8-dihydroneopterin triphosphate and 6-pyruvoyl-5,6,7, 8-tetrahydropterin) mediated by 6-pyruvoyl-tetrahydropterin synthase and sepiapterin reductase. 4 GTPCH is the rate limiting enzyme and is under negative feedback regulation by GTPCH feedback regulatory protein (GFRP) and BH 4 itself, and positive feedback by phenylalanine. 5 GTPCH is also regulated at the expression level, being increased by calcium 6 and 3-hydroxy-3-methylglutaryl (HMG)-coenzyme A (CoA) reductase inhibition, 7 and by cytokines such as interferon-␥, tumor necrosis factor-␣, and interleukin-1. Cytokine activation may involve coordinated activation of NF-B and the Jak2/Stat pathway, 8 and can increase BH 4 levels by increasing GTPCH-1 expression, 9 -12 reducing GFRP expression, 5 and increasing PTPS expression. 12 BH 4 synthesis is also stimulated by insulin via a phosphatidylinositol-3-kinase-dependent activation of GTPCH-1, 13 whereas insulin-resistant states impair this mech...