H ypertension and heart failure are marked by activation of both the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system. These forms of neurohumoral activation, in turn, have deleterious effects on the heart, kidney, and other target organs, worsening the prognosis in these disease states. Pharmacological agents that interrupt the RAAS are useful in both improving hemodynamics and preventing morbidity and mortality in such patients. In particular, treatment with ACE inhibitors has been shown to improve survival in patients with advanced heart failure and after myocardial infarction. It is hypothesized that ACE inhibitors exert beneficial effects by inhibiting both circulating and cardiac tissue ACE, thus attenuating unfavorable remodeling of the left ventricle (LV), reducing afterload, and improving the balance between thrombotic and thrombolytic factors. It remains unclear whether the dominant mechanism of action of ACE inhibitors in the setting of LV dysfunction relates to their global hemodynamic effects (which result in improved loading conditions), to reduced production of angiotensin (Ang) II with subsequent diminished Ang II type 1 (AT 1 ) receptor activation, or to alteration of other neurohormonal systems, such as the kallikrein-kinin system.
See p 2359Importantly, in addition to generating Ang II from Ang I, ACE catalyzes the degradation of bradykinin (BK) to inactive metabolites. 1 Studies of recombinant full-length ACE have shown that the apparent K m of ACE for BK is substantially lower than for Ang I, which indicates more favorable kinetics for hydrolysis of BK than for conversion of Ang I to Ang II. 2 Furthermore, site-directed mutagenesis demonstrated that the K m for BK was lower than that for Ang I at both N and C active sites of ACE, which suggests that at physiological concentrations, BK could be a preferential substrate over Ang I at both active sites of ACE. 2 The biological effects of BK and other kinins are mediated by stimulation of specific receptors, classified as BK 1 and BK 2 , both of which have been cloned and extensively characterized. 3 BK 1 receptors are expressed mainly in pathological conditions such as tissue injury and are thought to mediate the inflammatory and pain-producing effects of kinins; BK 2 receptors mediate most of the known cardiovascular effects of kinins. In the vasculature, BK-mediated activation of endothelial BK 2 receptors stimulates endogenous nitric oxide synthase (NOS), thus increasing NO and counteracting the effects of Ang II by inhibiting contraction and growth of smooth muscle cells. 4 Both BK 2 receptors 5 and NOS activity have been detected in cardiac myocytes, 6 and an intact kallikrein/kinin system has been found in the heart. 7 Kinins are detectable in the effluent of isolated perfused hearts and are increased by ACE inhibitors, as well as by ischemia, 8,9 which demonstrates that the cardiac kallikrein/ kinin system can be regulated.Studies in a mouse strain with targeted disruption of the BK 2 receptor gene have give...