See related articles, pages 888 894 and 947953
Angiotensin IIStimulated Vascular Remodeling
The Search for the Culprit Oxidase
Kaikobad Irani
H
ypertrophy and hyperplasia of vascular smooth mus-
cle cells are hallmarks of the common vascular
disorders of atherosclerosis, restenosis, and hyper-
tension and contribute to their long-term sequelae. Angioten-
sin II (Ang II) is a potent smooth muscle mitogen and
hypertrophic agent. The importance of Ang II in the patho-
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genesis of vascular disease is reflected in the efficacy of
angiotensin-converting enzyme inhibitors and Ang II receptor
blockers in the treatment of atherosclerosis and hypertension.
Despite the widespread use of these agents in clinical prac-
tice, our understanding of the mechanisms through which
Ang II exerts its effects on the vasculature is not complete.
The studies by Lassgue et al1 and Wang et al2 in this issue
of Circulation Research go a long way in elucidating the
molecular basis for the effects of Ang II on vascular smooth
muscle cell growth.
To fully appreciate the significance of the reported
findings, one has to place them into historical perspective.
The role of oxidative stress in the pathogenesis of the
above-mentioned vascular disorders has been well recog-
nized for some time.3 It has come to light that humoral
factors, such as Ang II, platelet-derived growth factor, and
thrombin, directly lead to oxidative stress in smooth
muscle cells via the generation of reactive oxygen species
(ROS), which are essential for their mitogenic and hyper-
trophic properties.4 7 With these findings in hand, inves-
tigators directed their efforts toward identifying the enzy-
matic source of growth factorstimulated ROS in vascular
smooth muscle cells.
Attention was mainly focused on identifying an oxidase
functionally analogous to the phagocyte NADPH oxidoreduc-
tase, because many but not all components of its multimo-
lecular complex are expressed in vascular smooth muscle
cells.7,8 However, attempts to show significant expression of
the enzymatically active flavoprotein subunit gp91phox of this
oxidase in smooth muscle cells were unsuccessful. Therefore,
The opinions expressed in this editorial are not necessarily those of the
editors or of the American Heart Association.
From the Division of Cardiology, Department of Medicine, Johns
Hopkins University School of Medicine, Baltimore, Md.
Correspondence to Kaikobad Irani, Ross 1023, The Johns Hopkins
University School of Medicine, 720 Rutland Ave, Baltimore, MD 21205.
E-mail kirani@jhmi.edu
(Circ Res. 2001;88:858-860.)
2001 American Heart Association, Inc.
Circulation Research is available at http://www.circresaha.org
858
the cloning of a homologous protein nox1 (NAD(P)H oxidase
1), originally termed mox-1 (mitogenic oxidase-1), from a
colon cancer cell line, and also expressed to a lesser extent in
rat vascular smooth muscle cells, was hailed as a significant
breakthrough.9 Other gp91phox homologues, expressed primar-
ily in the kidney10 and thyroid,11 have also been identified
recently.
This brings us to the present study by Lassgue et al,1
demonstrating for the first time the importance of the
newly discovered nox1 in Ang IIstimulated and platelet-
derived growth factorstimulated short-term ROS genera-
tion and activation of the growth-promoting signaling
proteins Akt and p38 mitogen-activated protein kinase in
cultured rat smooth muscle cells. In the absence of specific
means to inhibit nox1 activity, Lassgue et al use an
adenovirus encoding antisense nox1 to suppress its expres-
sion. The study also suggests that transcriptional upregu-
lation of nox1 by Ang II may be responsible for longer-
term growth of smooth muscle cells induced by this
mitogen. Standing alone, the study provides convincing
evidence for the role of nox1 in mitogen-stimulated
smooth muscle cell growth in vitro. However, on the basis
of the methodology used, it would be fair to say that the
data are not conclusive in this regard. Antisense, though
effective at suppressing nox1 expression, may not be
entirely specific. This leaves open the possibility, which is
acknowledged by the authors, that another homologous
oxidase, known or unknown, may also participate in
mitogen-stimulated ROS generation and growth.
The study by Wang et al,2 not coincidentally published
in this same issue, seems to contradict the in vitro findings
of Lassgue et al1 or at least question their physiological
relevance. Using knockout mice, Wang et al2 prove that it
is gp91phox, present primarily in endothelial cells and
adventitial fibroblasts but also expressed to a much lesser
degree in smooth muscle cells, that is chiefly responsible
for Ang IIstimulated vascular oxidative stress and smooth
muscle growth in vivo. This supports a previous report that
Ang II stimulates ROS production in adventitial fibroblasts
by inducing other components of the NADPH oxidase.12
Assuming for the moment that there is a mouse homologue
of nox1 (one has yet to be cloned) and ignoring possible
species-specific differences in the response to Ang II, there
are at least two explanations for the seemingly contradic-
tory findings embodied in these studies. The most straight-
forward one is that nox1 is not expressed in smooth muscle
cells in vivo or that expressed nox1 plays a small role, if
 Irani
Redox regulation of Ang IIstimulated smooth muscle cell
growth in the vascular wall. indicates growth inhibition.
Dashed arrow signifies indirect effect through induction of mito-
gens or change in mitogen-receptor interaction. eNOS indicates
endothelial nitric oxide synthase; p38MAPK, p38 mitogen-acti-
vated protein kinase; and SMC, smooth muscle cell.
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any, in smooth muscle hypertrophy and hyperplasia in
response to Ang II in vivo. On the contrary, it is gp91phox,
albeit expressed at very low levels in smooth muscle cells,
that mediates the effects of Ang II.
Another scenario, and one that is much more likely, is
that Ang IIstimulated, ROS-regulated smooth muscle
growth in vivo is not simply a function of ROS generated
by Ang II in smooth muscle cells, whether that be through
gp91phox, nox1, or other oxidases. Rather, in the complex
milieu of the vascular wall, smooth muscle growth is
dependent on the net balance between intracellularly
generated ROS (in smooth muscle cells), diffusible ROS
produced in adjacent cells in the endothelium and adven-
titia, and, perhaps most importantly, diffusible, endotheli-
um-derived nitric oxide (NO), a potent inhibitor of smooth
muscle hypertrophy and growth.13 In such an environment,
an increase in ROS (particularly diffusible and membrane-
permeable superoxide-derived H2O2) through gp91phox in
the endothelium and adventitia would, through direct or
indirect actions, lead to smooth muscle cell growth (Fig-
ure). These actions could include, but are not limited to,
counteracting the tonic inhibition on smooth muscle cells
by decreasing bioavailable endothelium-derived NO,14 di-
rect stimulation of smooth muscle mitogenesis and hyper-
trophy,15,16 elaboration of smooth muscle mitogens,17 or
changing mitogen-receptor affinity.18
It is important to note that the regulation of Ang
IIinduced smooth muscle proliferation or hypertrophy in
vivo by endothelial or adventitial gp91phox does not exclude
the expression of nox1 in medial smooth muscle cells nor
does it imply that Ang II does not lead to activation or
upregulation of nox1 in vivo. It does suggest, however,
that in a whole vessel, more powerful forces overshadow
the likely effect of nox1-derived ROS on medial hypertro-
phy: ROS and NO derived from the endothelium and
adventitia. To definitively demonstrate a role for nox1 in
medial growth in a physiological setting will require the
generation of nox1-null animals.
NAD(P)H Oxidases in Smooth Muscle Cell Growth 859
In summary, both the above-mentioned studies are signif-
icant advances toward understanding the molecular pathogen-
esis of Ang IIstimulated arterial remodeling. However, our
enthusiasm to embrace these findings should be tempered by
the reminder that our present understanding of and ability to
replicate the complex interactions between cells comprising
the vascular wall is still quite rudimentary. Thus, cellular and
even animal models of this disease may not be accurate
reflections of the human condition.
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KEY WORDS: NAD(P)H oxidase angiotensin II smooth muscle
medial hypertrophy reactive oxygen species
 Angiotensin IIStimulated Vascular Remodeling: The Search for the Culprit Oxidase
Kaikobad Irani
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Circ Res. 2001;88:858-860

doi: 10.1161/hh0901.091205
Circulation Research is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2001 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7330. Online ISSN: 1524-4571

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