SY 12-1 RENIN ANGIOTENSIN PATHWAY BEYOND ACE AND ANGIOTENSIN II RECEPTORS: HOW IT RELATES TO THE PATHOPHYSIOLOGY OF HYPERTENSION.

The renin-angiotensin system (RAS) plays a major role in the pathogenesis of hypertension, a major risk factor for stroke, coronary events, heart failure and kidney disease. Within the RAS, angiotensin converting enzyme (ACE) converts angiotensin (Ang) I into the vasoconstrictor Ang II, which mediates its effects via the angiotensin type 1 receptor (AT1R). An "alternate" arm of the RAS is now known to exist in which the monocarboxypeptidase ACE2 counterbalances the effects of the classic RAS through degradation of the vasoconstrictor peptide, Ang II, and generation of the vasodilatory peptide, Ang 1-7. ACE2 is highly expressed in tissues of cardiovascular relevance including the heart, blood vessels and kidney. The catalytically active ectodomain of ACE2 undergoes shedding resulting in ACE2 in the circulation. The finding that the ACE2 gene maps to a quantitative trait locus on the X chromosome in three strains of genetically hypertensive rats suggests that the ACE2 gene may be a candidate gene for hypertension. It is hypothesised that disruption of tissue ACE/ACE2 balance results in changes in blood pressure, with increased ACE2 expression protecting against increased blood pressure, and ACE2 deficiency contributing to hypertension. Studies in experimental models of hypertension have measured ACE2 gene, protein and/or activity, in either the heart or kidney and/or plasma, usually at one time point, and most commonly in animals with established hypertension. As experimental studies report that deletion or inhibition of ACE2 leads to hypertension, whilst enhancing ACE2 protects against the development of hypertension, increasing or activating ACE2 may be a therapeutic option for the management of high blood pressure in man. There have been relatively few studies of ACE2, either at the gene or the circulating level in patients with hypertension. The available data indicates that plasma ACE2 activity is low in healthy subjects, but elevated in patients with cardiovascular risk factors or cardiovascular disease. The majority of ACE2 genetic studies have examined the relationship of single nucleotide polymorphisms in the ACE2 gene with either hypertension or systolic and diastolic blood pressure, and have produced largely inconsistent findings. This Lecture will discuss the evidence regarding the role of ACE2 in the pathophysiology of experimental and human hypertension.