Review 25

Novel therapies blocking the reninangiotensinaldosterone

system in the management of hypertension and
related disorders
Henry Kruma and Richard E. Gilbertb,c
Although significant advances have been made in the
therapeutic blockade of the reninangiotensin
aldosterone system (RAAS) using angiotensin-converting
enzyme (ACE) inhibitors, angiotensin receptor blockers and
non-selective aldosterone receptor antagonists, there is a
clear need for both additional blocking strategies and
enhancements of current therapeutic approaches.
Vasopeptidase inhibition may still find a role despite the
small incremental value of this approach and the obvious
issue of kinin-mediated adverse effects still to be fully
addressed. Blockade of the RAAS upstream using renin
inhibitors as well as the greater selectivity of aldosterone
blockade using selective aldosterone blockers such as
eplerenone are also novel approaches. Not yet in clinical
use but certainly an attractive therapeutic target is
angiotensin II growth factor receptor transactivation, with
selective inhibitors having been developed for various
specific kinase pathways. Finally, ACE2 augmentation,
antisense gene strategies, and vaccination against the
reninangiotensin system should still be considered

Introduction
The treatment of essential hypertension has advanced
considerably in the past few decades. We now have agents
that are highly effective at lowering blood pressure
(BP), are associated with minimal side effects, and are
able to be given on a once daily basis to aid adherence to
therapy. The question therefore arises as to why we need
new treatments in the management of this condition.
There are a number of reasons for this. One of the most
important is that target BP goals continually move lower
based on epidemiological and intervention study data [1].
This is particularly true of hypertension associated with
co-morbid conditions such as diabetes mellitus. For this
reason, monotherapy alone is usually not able to lower BP
to these target levels in a sufficient percentage of patients.
The use of multiple classes of agents within the individual patient has therefore become the norm. However,
certain agents may interfere with the BP-lowering efficacy
of other agents, for example, renin inhibition with betablockers when used with angiotensin-converting enzyme
(ACE) inhibitors or angiotensin receptor blockers (ARBs).
Therefore, the clinical need for new therapies as add-on
treatments for refractory hypertension and to attack new
targets still remains highly relevant.
Blockade of the reninangiotensinaldosterone system
(RAAS) is an important therapeutic strategy not only for

experimental, but have significant appeal as additional

approaches to the blockade of this system. J Hypertens
25:2535 Q 2007 Lippincott Williams & Wilkins.
Journal of Hypertension 2007, 25:2535
Keywords: aldosterone, angiotensin, hypertension, neutral endopeptidase,
renin, renin inhibitors
a
Department of Epidemiology and Preventive Medicine, Monash University,
Melbourne, Australia, bDepartment of Medicine, University of Toronto, St
Michaels Hospital, Ontario, Canada and cDepartment of Medicine, University of
Melbourne, St Vincents Hospital, Melbourne, Australia

Correspondence and requests for reprints to Henry Krum, NHMRC Centre of

Clinical Research Excellence in Therapeutics, Department of Epidemiology and
Preventive Medicine, Monash University/Alfred Hospital, Central and Eastern
Clinical School, Melbourne, Victoria 3004, Australia
Tel: +61 3 9903 0042; fax: +61 3 9903 0556;
e-mail: henry.krum@med.monash.edu.au
Conflicts of interest: none.
Received 17 May 2006 Revised 20 September 2006
Accepted 25 September 2006

See editorial commentary on page 41

the treatment of hypertension, but also for the clinical

benefits that it provides beyond BP reduction, such as in
the management of heart failure and progressive kidney
disease [2]. To date, interruption of this system has been
affected at multiple steps that include enzyme inhibition
(ACE and renin) in addition to receptor blockade (angiotensin II type 1 receptor and aldosterone; Fig. 1) [3].
ACE inhibitors were originally developed with the
thought that these agents may be particularly effective
in patients with marked activation of the RAAS, namely
high renin-secreting patients. However, it transpired
early in their development that these agents were also
highly effective at lowering BP irrespective of the plasma
renin status or activation of the system [4]. The advent of
ARBs provided an alternative mechanism of blockade of
the adverse effects of angiotensin II on the vasculature
and heart [5]. Furthermore, these agents also offered an
improved adverse event profile in comparison with
ACE inhibitors, with reduced kinin-mediated effects
such as cough [5]. In practice, however, both cough
and angioneurotic oedema (another bradykinin-related
adverse effect) has been observed with ARBs [6].
Aldosterone has, of late, been recognized as a major
independent adverse hormone in the pathogenesis and
progression of a number of major cardiovascular disease

0263-6352 2007 Lippincott Williams & Wilkins

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

26 Journal of Hypertension 2007, Vol 25 No 1

Fig. 1

Angiotensinogen
Renin

Angl
ACE2
ACE

Angll

Ang(1 9)
ACE

ACE2

Ang(17)

Vasoconstriction

Vasodilation

Na/H2O reabsorption

Diuresis and natriuresis

Hypertrophy/hyperplasia

Anti-proliferative

Production of reactive oxygen

species

Stimulation of BK and NO
release

Overview of reninangiotensin system pathway. After its formation from

angiotensinogen by renin, angiotensin I (AngI) can be further cleaved by
angiotensin-converting enzyme (ACE) to yield angiotensin II (AngII),
or alternatively converted by ACE2 to angiotensin 19 [Ang (19)],
a substrate for ACE, converts it to Ang (17). In addition, ACE2 can
also cleave angiotensin II to form Ang (17). Although angiotensin
leads to a range of effects that are regarded as mostly injurious, Ang
(17) is vasodilatory, natriuretic and anti-inflammatory. Taken from Der
Sarkissian et al. [3] with permission. BK, Bradykinin; NO, nitric oxide.

states, including essential hypertension [7]. Aldosterone

receptor blockade with spironolactone has been a mainstay of therapy for hypertension and chronic heart failure
as well as a number of non-cardiac disease states over
many decades. However, this agent suffers from receptor
non-specificity, manifest as progestational and antiandrogenic adverse effects [8].
On the basis of the above considerations, the RAAS
remains a major target for therapeutic intervention with
a clear need for further novel and alternative approaches
to the blockade of this system. This review will explore a
number of such novel targets and approaches to blockade,
specifically in the context of the management of essential
hypertension.

Vasopeptidase inhibition
The humoral control of the cardiovascular system
involves both vasoconstrictive and vasodilatory peptides,
with the natriuretic peptides (ANP, BNP, CNP) providing endogenous antagonism to angiotensin II [9]. The
natriuretic peptides are removed from the circulation
primarily as a result of enzymatic degradation by neutral
endopeptidase (NEP) and to a lesser extent through

clearance by the natriuretic clearance receptor [10].

Moreover, in addition to the natriuretic peptides, NEP
also catalyses the degradation of vasodilatory kinins and
adrenomedullin [10]. Therefore, in theory, inhibition of
the RAAS combined with potentiation of natriuretic
peptides/kinins should lead to improved cardiovascular
haemodynamics and sodium/water balance [11]. Moreover, the structural similarities in the active sites of both
NEP and ACE had made the simultaneous inhibition of
these two enzymes an attractive target for drug development. A number of such dual vasopeptidase inhibitors
(VPI) entered preclinical and clinical development in
the 1990s. These agents, which vary in their inhibitory
activity for ACE and NEP, include omapatrilat, SA
7060, MDL 100240, MDL 10017, fasidotril, sampatrilat,
alatriopril, CGS 30440 and S 21402 [12].
Of the dual VPI, omapatrilat has been the most extensively studied in clinical trials. In early studies with this
compound, it was shown to be superior to ACE inhibitors
as an antihypertensive agent and in the treatment of
heart failure [13]. Although initially attributed to benefits
beyond ACE inhibition, omapatrilat was shown to be
a weak diuretic, with thiazide diuretics providing
additional BP reduction. These findings led to the conclusion that the efficacy of omapatrilat in hypertension
and heart failure may be attributable in large part to the
potentiation of kinins. Despite the immense enthusiasm
generated by initial studies, larger definitive studies were
ultimately unsuccessful. For example, in the Omapatrilat
Cardiovascular TreAtment Versus Enalapril (OCTAVE)
trial, 25 302 hypertensive subjects were randomly
assigned to receive either omapatrilat 80 mg or enalapril
40 mg once a day [14]. Omapatrilat reduced systolic
blood pressure (SBP) 3.6 mmHg more than enalapril at
week 8, with less use of adjunctive antihypertensive
therapy needed to reach the BP target. However, angioedema was more frequent with omapatrilat than enalapril
(2.17 versus 0.68%), with two omapatrilat-treated subjects experiencing airway compromise. Although the
mechanisms underlying the development of angioedema
with omapatrilat are incompletely understood, this
adverse effect is viewed as pharmacodynamic rather than
idiosyncratic, with rapid increases in bradykinin being
contributory.
In the Omapatrilat Versus Enalapril Randomized Trial of
Utility in Reducing Events (OVERTURE) [15], 5770
patients with New York Heart Association class II to IV
heart failure were randomly assigned to treatment with
either enalapril 10 mg twice a day or omapatrilat 40 mg
once a day for a mean of 15 months. Although omapatrilat
reduced the risk of death and hospitalization, it was not
more effective than ACE inhibition alone in reducing the
risk of a primary clinical event. Moreover, a trend towards
an increased likelihood of angioedema was once again
noted (omapatrilat 0.8% and enalapril 0.5%).

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Novel inhibitors of the RAAS Krum and Gilbert 27

Therefore, despite the immense theoretical appeal of

blocking both ACE and NEP, the limited incremental
benefit of this drug class along with the greater possibility
of angioedema has limited its potential utility. However,
the fact that newer VPI, such as M100240 (Sanofi Aventis,
Paris, France) are currently entering early phase human
trials suggests that this class of drug may still have a future
in the clinic.

Renin inhibition
Angiotensin II, a major effector molecule of the RAAS, is
produced by a two-step process in which angiotensinogen, synthesized primarily in the liver, is cleaved by the
aspartic peptidase, renin, produced in the juxtaglomerular cells of the kidney, to give rise to angiotensin I. This
biologically inactive decapeptide is then converted to the
active octapeptide angiotensin II by the di-peptidyl
carboxypeptidase ACE or by a range of other proteases
that include chymase [16].
Although highly effective, the therapeutic response
achieved with both ACE inhibitors and ARBs is limited
by the reactive rise in renin (and thus angiotensin peptides) that occurs with both drug classes [17]. Renin is not
only the rate-limiting step in angiotensin II formation but
also shows remarkable substrate specificity for angiotensinogen, making it an attractive target for therapeutic
inhibition.
The reninangiotensin system (RAS) has long been
recognized as playing a key role in the pathogenesis of

organ fibrosis, after the recognition that angiotensin II,

acting via the angiotensin II type 1 receptor (AT1R), is a
potent inducer of the profibrotic growth factor, transforming growth factor beta (TGF-b) [18]. However, the recent
identification of a renin/prorenin receptor in the glomerular mesangium and arterial subendothelium indicate
that other mechanisms may also contribute to the interaction between the RAS and TGF-b [19]. For example,
binding of renin or prorenin to this receptor not only
increases the catalytic efficiency of the former in angiotensin I formation, but also converts the otherwise inert
prorenin into an active moiety [19], together leading to
increased local angiotensin II concentration (Fig. 2) [20].
Moreover, the interaction between either renin or prorenin with its receptor can also lead to TGF-b formation
[21] and other potentially pathogenetic pathways such as
mitogen-activated protein kinase, in the absence of
angiotensin peptide formation [22]. Together these
renin/prorenin receptor-mediated actions suggest that
renin inhibition may have additional organ protective
effects beyond those seen with ACE inhibitors and
ARBs [20].
Despite the attractiveness of renin inhibition and the
success of early compounds in validating it as a therapeutic target, further drug development has been marred
by issues of potency, bioavailability, duration of action
and costs of synthesis. For example, although potent,
renin inhibitors such as remikiren and enalkiren showed
poor oral bioavailability [23]. Although this was
improved somewhat with agents such as zankiren and

Fig. 2

Renin

Renin

Angiotensin

Prorenin

Prorenin

Ang

Angiotensin

Angiotensin

TGF-

Renin

TGF-

TGF-

Mesangial cell
Reninangiotensintransforming growth factor beta (TGF-b) interactions in mesangial cells of the kidney. The reninangiotensin system interacts
with TGF-b by a number of potential mechanisms. These include the induction of TGF-b expression by angiotensin II acting via the AT1 receptor,
binding of renin or prorenin to the renin/prorenin receptor enhancing the catalytic activity of renin leading to increased angiotensin II formation, and
TGF-b generation by activation of the renin/prorenin receptor. Taken from Oliver [20] with permission.

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

28 Journal of Hypertension 2007, Vol 25 No 1

terlakiren [23], further development of renin inhibitors

was halted in the mid-1990s in the setting of the development of ARBs. In particular, the chemical synthesis of
renin inhibitors was during the 1970s, 1980s and 1990s (and
remains) more complex than the synthesis of ARBs.
More recently, programmes to develop renin inhibitors
have been reactivated. However, rather than being based
on the structure of angiotensinogen, the drug design
for these new programmes has been based on X-ray
crystallography of renins active site with computational
modelling, leading to the synthesis of a series of
novel renin inhibitors with the hope of overcoming previous problems. Of these, aliskiren (2(S),4(S),5(S),7(S)N-(2-carbamoyl-2-methylpropyl)-5-amino-4-hydroxy-2,7diisopropyl-8-[4-methoxy-3-(3-methoxypropoxy)phenyl]-octanamid hemifumarate, SPP100; Speedel/Novartis, Basel, Switzerland) is the most advanced of the new
class of orally active, non-peptide, low-molecular-weight
renin inhibitors [24]. It has a number of favourable
attributes to its profile, being highly potent (IC50
0.6 nmol/l) for human renin with a plasma half-life of
approximately 24 h.
Aliskiren has been studied in a number of animal models
of hypertension and its end-organ effects. In general, BPlowering has been as would be expected with downstream reninangiotensin blocking agents.
Because renin displays specificity for its substrate, renin
inhibitors cannot be tested efficiently in conventional
hypertensive rat models. For this reason, transgenic rats
and mice have been developed that overexpress both the
renin and angiotensin genes, namely double transgenic
rats. In such a model, aliskiren was shown to reduce BP
and albuminuria and normalize serum creatinine [25]. It
also increased survival compared with untreated double
transgenic rats, reduced cardiac hypertrophy, decreased
left ventricular wall thickness and improved the E to A
ratio [25]. These findings support renin inhibition as
being of potential benefit in end-organ protection secondary to systemic hypertension, particularly involving
the heart and kidney.
In healthy volunteers, aliskiren (40640 mg/day) administered by mouth was well tolerated, inducing a dosedependent decrease in plasma renin activity, and angiotensin I and II concentrations [26].
Clinical studies in hypertension patients with aliskiren
have demonstrated dose-dependent reductions in BP,
with similar safety and tolerability to ARBs. In a study
of 652 patients with mild to moderate hypertension,
aliskiren at doses of 150300 or 600 mg demonstrated
dose-dependent BP lowering [27]. The 150 mg a day dose
of aliskiren was similar in BP lowering to irbesartan
150 mg a day over an 8-week study period [27].

In 226 patients with mild to moderate essential hypertension, aliskiren 37.5300 mg a day resulted in a dosedependent reduction in ambulatory BP levels over a
4-week period [28]. Again, aliskiren appeared to be well
tolerated at all dose levels studied. Losartan 100 mg a day
was similar to the three highest doses of aliskiren in BP
lowering (i.e. 75, 150 and 300 mg/day) [28]. Beyond
300 mg a day, gastrointestinal tolerability appears to be
a dose-limiting issue with aliskiren.
Reported but not as yet published are phase IIB/III data
comprising 1064 patients in an 8-week study comparing
three doses of valsartan with three doses of aliskiren or
placebo. Aliskiren resulted in similar BP lowering to
valsartan, with the suggestion of additive BP-lowering
effects when the two agents were used together [29].
This may relate to incomplete blockade of the RAAS by
the valsartan doses used in the studies.
On the basis of those studies it seems likely that renin
inhibitors will provide reductions in cardiovascular and
renal morbidity in patients with systemic hypertension.
Whether these agents are similar, inferior or superior to
ACE inhibitors and ARBs is at present unclear. Similarly,
extensive clinical evaluation with hard endpoints will be
required to ascertain whether the combination of renin
inhibition with ACE inhibitors or ARBs, in providing
more complete blockade of the RAS, also leads to further
improvements in morbidity and mortality.

Novel approaches to aldosterone blockade

The hormone aldosterone has been a well-known target
for therapeutic intervention for many decades.
Aldosterone, as a hormone, was first described in 1954
when its steroid structure was discovered [30]. It was
known to have potent actions on sodium retention and
potassium excretion at the renal distal convoluted tubule,
and to a lesser extent at other epithelial sites such as
salivary glands and the gastrointestinal tract. These socalled epithelial effects are mediated by the binding of
aldosterone to the mineralocorticoid (type I glucocorticoid receptor), interaction of the ligandreceptor complex with DNA and eventual modulation of gene
expression.
Aldosterone also exerts a variety of non-epithelial effects
based on the discovery of mineralocorticoid receptors in
multiple non-epithelial sites [31]. In contrast to interactions with nuclear receptors, the non-epithelial effects
of aldosterone appear to be mediated by a second messenger system that involves the activation of a sodium
hydrogen antiporter [31]. These non-epithelial receptors
have been found to be present in the heart [32] and
vascular tissue [33], the stimulation of which causes
pathological fibrosis and remodelling [3436]. Nonepithelial actions of aldosterone on the kidneys [37] have

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Novel inhibitors of the RAAS Krum and Gilbert 29

recently been discovered, including the direct induction

of glomerulosclerosis and proteinuria, which may occur
independent of effects on BP.

effect of eplerenone in this setting, or merely the proteinuria benefits of non-specifically increasing sodium
excretion in the setting of ACE inhibition.

As would be predicted by the above sites of action, the

stimulation of mineralocorticoid receptors (particularly in
the presence of salt loading) contributes not only directly
to hypertension but also to its complications, including
atherosclerosis, left ventricular hypertrophy and concomitant heart failure, via necrosis, pathological fibrosis and
increased catecholamine release [38].

To assess the renal effects of eplerenone, 257 hypertensive patients with type 2 diabetes mellitus and microalbuminuria were prescribed either eplerenone (n 89),
enalapril (n 83) or the combination (n 85) for 24
weeks [42]. Reductions in the urinary albumin to creatinine ratio were 62, 45 and 74% for the three groups,
respectively (P 0.015 eplerenone versus enalapril,
P 0.018 combination versus eplerenone and P < 0.001
combination versus enalapril), despite similar reductions
in BP. Both drugs were well tolerated, with no reports of
gynecomastia, but hyperkalemia occurred in eight, two
and eight subjects of the eplerenone, enalapril and combination groups, respectively.

Selective aldosterone receptor blockers

Spironolactone has been approved for many decades in

the treatment of mineralocorticoid hypertension, ascites
associated with portal hypertension and chronic heart
failure. It has been widely used for the treatment of
undifferentiated (essential) hypertension. However, this
agent has been limited by its non-specificity for mineralocorticoid receptors, including anti-androgenic and prooestrogenic actions. For example, in the RALES trial
[39], 10% of male patients reported gynaecomastia.
On this basis, a more highly selective agent for the
mineralocorticoid receptor was developed by replacing
the 17-alpha-thoacetyl group with a carbomethoxy
group [40]. This new agent, eplerenone, has been studied
in a large programme exploring the potential benefits
of the agent as monotherapy and add-on therapy in
patients with essential hypertension, both undifferentiated and in those with low renin/high aldosterone
plasma levels.
To date, a number of double-blind, randomized clinical
trials have contributed to the database for the efficacy and
safety of eplerenone in systemic hypertension.
The effects of eplerenone on left ventricular hypertrophy
and renal function associated with mild to moderate
hypertension were assessed in a 9-month study [41] of
patients who received one of eplerenone (n 50), enalapril (n 54) or the combination (n 49). Although the
BP effects were similar, mean reductions in left ventricular mass were 7.6, 10.5 and 14.1% in the three groups,
respectively (P 0.007 eplerenone versus combination,
P 0.107 enalapril versus combination). The equivalent
figures for reductions in the urinary albumin to creatinine
ratio were 24.9, 37.4 and 52.6% (P 0.001 eplerenone
versus combination, P 0.038 enalapril versus combination). More cough was experienced by patients
assigned to the enalapril group than the eplerenone group
(14.1 versus 3.1%, P 0.033).
A limitation of this study was the absence of a comparator
group of enalapril and thiazide to determine if this
provided the same benefit as the enalapril/eplerenone
group. Therefore it remains uncertain if there is a specific

To examine whether low-renin essential hypertension

was more responsive to aldosterone receptor antagonism
than the antagonism of angiotensin II (as a result of
greater salt sensitivity), a sample of patients with this
condition received either eplerenone (n 86) or losartan
(n 82) for 8 weeks, after which hydrochlorothiazide
could have been added if necessary for another 8 weeks
[43]. At week 8, the mean change in SBP/diastolic BP
was significantly greater in the eplerenone group. At
week 16, the mean change in SBP/diastolic BP was
similar between the treatment groups, but fewer patients
in the eplerenone group required dual therapy (32.5
versus 55.6%). Increases in renin activity were similar,
but the increase in aldosterone levels was greater for the
eplerenone group. The adverse effect profiles were
similar.
An 8-week study assessed the co-administration of eplerenone with an ACE inhibitor or ARBs among patients
with mild to moderate hypertension: ACE inhibitor plus
eplerenone (n 87), ACE inhibitor plus placebo (n 90),
ARBs plus eplerenone (n 83), and ARBs plus placebo
(n 81) [44]. ARBs plus eplerenone was significantly
more effective than ARBs alone in reducing BP, whereas
an ACE inhibitor plus eplerenone seemed to be more
effective than an ACE inhibitor alone in reducing SBP
only. Adverse events did not differ significantly across the
treatment groups and were generally not severe. In an
ad-hoc analysis, neither baseline values of plasma renin
activity or serum aldosterone (or the ratio) predicted the
BP response to treatment [45].
Further studies have examined eplerenone as monotherapy compared with enalapril [46], losartan [47] and amlodipine [48]. Ambulatory monitoring studies [49] and
evaluation in black patients [50] have also been performed. Those studies demonstrate consistent effects
regarding the efficacy and safety of this approach in
the management of hypertension.

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

30 Journal of Hypertension 2007, Vol 25 No 1

In summary, the effect of eplerenone on BP and left

ventricular mass appears to be similar to that of ACE
inhibitors, but eplerenone may confer greater renoprotection and may be associated with fewer adverse events.
It also appears superior to ARBs for the treatment of
patients with low-renin hypertension. If BP is uncontrolled by ACE inhibitors or ARBs alone, the addition of
eplerenone can be safely considered, and need not be
dictated by plasma renin activity nor aldosterone levels.
Among patients with diabetes mellitus, eplerenone combined with an ACE inhibitor appears to be more efficacious than either agent alone in regressing left ventricular
mass and renal impairment, and these effects may occur
independently of BP reduction.
Importantly, those studies, together with the large
EPHESUS study in post-myocardial infarction heart
failure observed no increase in gynecomastia and other
anti-androgenic adverse effects compared with placebo,
for example chlorthalidone 12.525 mg a day.
Nevertheless, the long-term efficacy and safety profile of
eplerenone remains uncertain. With regard to safety,
there are no data at present to suggest that eplerenone
is less likely to cause clinically significant hyperkalemia
than spironolactone. A major deficiency of the hypertension study programme with eplerenone has been the
absence of direct comparative studies, at appropriate
doses (50100 mg/day) with thiazine diuretics. Moreover,
there are few clinical data on eplerenone and its utility in
primary aldosteronism. Taken together, however, these
data suggest considerable promise for eplerenone in the
management of systemic hypertension.
Aldosterone synthase inhibitors

Another approach to blocking the effects of mineralocorticoid receptor activation is to inhibit the production of
the endogenous ligand, aldosterone. This can be
achieved by a number of approaches to interference with
the pathway of aldosterone synthesis. The last step in this
pathway is conversion to mature aldosterone by the
enzyme aldosterone synthase (aldo synthase) [51].
Interestingly, the transgenic overexpression of aldosynthase results primarily in marked coronary endothelium-dependent dysfunction, probably secondary to
perivascular fibrosis [52]. Selective aldo synthase inhibitors have been developed and are currently undergoing
preclinical evaluation. One advantage may be the
absence of reflex activation of the upstream RAS as
occurs with specific aldosterone receptor blockers in
which there is an activation of renin, angiotensin II
and aldosterone to overcome the blockade.
As there are no known alternative pathways of mature
aldosterone generation, aldo synthase inhibitors are unlikely to be associated with issues of bypass of this enzyme

as with ACE inhibitors, in which other enzymes such as

chymase may be operative in the conversion of angiotensin I to angiotensin II.
Further study is required to determine the extent of the
BP-lowering efficacy and safety of this approach to the
blockade of mature aldosterone production.

Angiotensin II growth factor receptor

transactivation
Although initially viewed as a purely vasoactive hormone,
evidence accumulated over more than a decade suggests
that angiotensin II, the dominant effector molecule of the
RAS, may also act as a growth factor in responsive tissues,
such as those of the cardiovascular system and kidney
[53,54]. These growth factor-like effects include cell
hypertrophy [55,56] and the synthesis of extracellular
matrix [57,58], together contributing to angiotensin
II-induced organ injury. In addition to its direct haemodynamic effects and the ability to induce increased
growth factor expression, angiotensin II, by binding to
its type 1 receptor (AT1R), has also been shown to
transactivate the growth factor receptor tyrosine kinases
for epidermal growth factor (EGF) [59,60] and plateletderived growth factor (PDGF) [61,62].
Epidermal growth factor receptor tyrosine kinase
activation

The complex mechanisms underlying the transactivation

of EGF receptor by angiotensin II have recently begun to
be unraveled [63]. By binding to the AT1R, angiotensin II
induces the translocation of tumour necrosis factor alpha
(TNF-a) converting enzyme (TACE, ADAM17) to the
cell surface. This metalloprotease then cleaves TNF-a
from its membrane-associated precursor (pro-TNF-a),
allowing it to bind to its cognate receptor, EGF receptor,
at the cell surface. This ligandreceptor interaction then
induces EGF receptor autophosphorylation and consequently the activation of downstream signaling pathways that include akt, erk-1/2 and mammalian target of
rapamycin (Fig. 3) [64].
The in-vivo relevance of this transactivation pathway has
recently been confirmed. Using mice that express a dominant negative form of EGF receptor, Lautrette and colleagues [63] showed that despite similar BP, mutant mice
infused with angiotensin II exhibited less proteinuria and
kidney fibrosis than did their wild-type counterparts. Consistent with these findings and the pivotal role of the RAS
in diabetic nephropathy, studies using the specific EGF
receptor tyrosine kinase inhibitor, PKI 166 (Novartis) have
also shown a reduction in early structural injury in a rat
model of diabetic nephropathy [65].
Platelet-derived growth factor receptor tyrosine kinase

Like EGF receptor, the transactivation of the PDGF

receptor by AT1R is also complex, involving a unique

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Novel inhibitors of the RAAS Krum and Gilbert 31

Fig. 3

Schematic diagram of angiotensin II (ANG II)-mediated transactivation of the epidermal growth factor (EGF) receptor. Angiotensin II binds to its AT1
receptor, a G-protein coupled receptor that lacks intrinsic tyrosine kinase activity. Through yet undescribed mechanisms, this interaction leads to the
translocation of the metalloprotease tumour necrosis factor alpha (TNF-a) activating enzyme (TACE) from the cytosol to the cell surface, where it
cleaves TNF-a from its membrane-associated promolecule, allowing it to bind and activate the EGF receptor. Taken from Wolf [64] with permission.

pathway that includes the adaptor protein Shc [61,62]. In

addition to studies that have explored the angiotensin
PDGF receptor interaction in cell culture or organ baths
[66], a more recent report has shown that despite continued hypertension, the inhibition of PDGF receptor
kinase in vivo can also dramatically attenuate angiotensin
II-induced vascular remodeling [67] (Fig. 4).
Growth factor receptor tyrosine kinase inhibitors

Increased activity of growth factor receptor tyrosine

kinases, as a consequence of their aberrant overexpres-

sion or their uncontrolled activation has been implicated

in the pathogenesis of several malignancies. For example,
overactivity of the EGF receptor family of tyrosine
kinases (HER-1/EGFR, HER-2, HER-3, HER-4,
mutant EGFRvIII) is viewed as a determining feature
of several malignancies, including those of the breast,
lung, colon and brain. Accordingly, a number of small
molecules that inhibit the EGF receptor family of receptor kinases have been synthesized, evaluated and are in
current clinical use, providing a relatively non-toxic
addition to the cancer chemotherapy armamentarium

Fig. 4

Photomicrographs of mesenteric arteries from control rats (left) and those subjected to angiotensin II infusion with (right) and without (centre) the
platelet-derived growth factor receptor kinase inhibitor, imatinib. Tissues have been stained with Massons trichrome whereby smooth muscle is
stained pink and collagenous matrix is stained blue. Taken from Kelly et al. [67] with permission.

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

32 Journal of Hypertension 2007, Vol 25 No 1

Small molecule tyrosine kinase inhibitors in clinical

development

Table 1
Target

Compounds

Epidermal growth factor receptor family of

tyrosine kinases

Gefitinib (Iressa, ZD1839),

Astra Zeneca
Erlotinib (Tarceva, OS1774),
Roche/Genetech/OSI
PD183805, Pfizer
EKB569, Wyeth-Ayerst
GW2016, Glaxo Smith-Kline
SU6668, Sugen/Pfizer
SU11248, Sugen/Pfizer
CHR200131, Chiron
CEP7055, Cephalon
AG13736, Pfizer/Aguron

Fig. 5

Angiotensinogen
Renin

Platelet-derived growth factor receptor

tyrosine kinases

Kininogen

Angiotensin I (110)
ACE

Bradykinin

Chymase
carboxypeptidase
cathepsin G
tonin

Angiotensin 17

Angiotensin II (1 8)
Aminopeptidase A

Angiotensin III (28)

Aminopeptidase M

Angiotensin IV (3 8)

Adapted from Brilla et al. [32].

(Table 1) [32]. Like the EGF receptor, the PDGF

receptor is also involved in the proliferation of malignant
cells and may also play a role in tumour neoangiogensis
[68]. Although a number of PDGF receptor kinase inhibitors have undergone clinical evaluation, compounds to
date have also shown activity against a number of other
kinases (Table 1). For example, although imatinib is a
potent inhibitor of the PDGF receptor kinases, it also
inhibits c-abl and c-kit at similar concentrations [69].
Given the knowledge that many patients with chronic
diseases such as heart failure and diabetic nephropathy
have similar 5-year survival rates to those with several
types of malignancy, the use of a pharmacological inhibitor of EGF receptor and PDGF receptor kinases beyond
oncology seems rational.

Angiotensin-converting enzyme 2 as a
therapeutic target
In 2000, a homologue of ACE with 42% sequence
homology was identified by genome-based strategies
[70]. Like ACE, this enzyme, named ACE2, ACE-related
carboxypeptidase and ACE homologue (ACEH), is also a
zinc-containing membrane-associated exopeptidase.
However, unlike ACE, which cleaves the two amino
acids from the carboxyl terminal of substrate peptides,
ACE2 cleaves only a single C-terminal amino acid.
Accordingly, it converts angiotensin II to Ang(17) and
angiotensin I to Ang(19). The latter, in turn, is a substrate for ACE, converting Ang(19) to Ang(17) (Fig. 5).
Whereas angiotensin II is viewed as the effector molecule
of the RAS, Ang(17) appears to be the main effector
peptide of ACE2 with vasodilatory, natriuretic and antiinflammatory properties (Fig. 6) [71]. The effects of
hydrolysis of other ACE2 substrates such as apelin,
dinorphin and neurotensin is less well defined [72].
A number of major findings suggest that ACE2 and
Ang(17) play important roles in the cardiovascular
pathophysiology, serving among other things as a key
modulator of excessive RAAS activity [3]. Deletion of the

Schematic representation of breakdown of angiotensinogen into

bioactive fragments and kinin generation by angiotensin-converting
enzyme (ACE). In addition to angiotensin II, a number of other
biologically active peptides can be generated through the action of
various peptidases. These include angiotensin III, angiotensin IV and
angiotensin 17, with specific receptors identified for the latter two.

ACE2 gene results in severely impaired cardiac contractility and increased angiotensin II [73], whereas the
overexpression of Ang(17) has cardioprotective effects
[74]. Furthermore, in keeping with the role of ACE2 as a
modulator of excessive RAS activity, lentivirus-induced
ACE2 overexpression significantly attenuates angiotensin.
As part of discovery programmes, a number of inhibitors
of ACE2 have been synthesized, providing potential
reagents to advance our understanding of the role of this
enzyme in both the normal physiology and in disease
states [3]. Such inhibitors include both peptides such as
DX600 [75] and non-peptidic compounds such as MLN4760 [76]. However, based on our current understanding,
it seems likely that therapeutic modulation of ACE2
would involve enhancing its activity rather than inhibiting it. To date, this has been confined to the use of
recombinant peptide [77] and gene therapy approaches
[78]. Nevertheless, given the potential importance of
enhancing ACE2 activity, other strategies are also likely
to be developed.

Blockade of reninangiotensin system

activity using antisense gene therapy
Antisense gene delivery strategies have been studied to
block the RAAS. Targets within the system include
angiotensinogen, the AT1R and angiotensin I-converting
enzyme [79]. The inhibition of hypertension in
spontaneously hypertensive rats and other high BP
animal models has been observed using these treatment
strategies [80,81]. The particular advantage of this
approach is that because of its long-lasting effects, compliance with therapy is minimized as a critical management issue.

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Novel inhibitors of the RAAS Krum and Gilbert 33

Fig. 6

Schematic diagram showing the interaction between angiotensin-converting enzyme (ACE) and ACE2 in the generation of angiotensin II peptides.
Angiotensin II generated by ACE can bind to either the AT1 receptor, inducing injury and oedema or to the AT2 receptor, reducing these effects.
ACE2, on the other hand, inactivates angiotensin II, cleaving it to form the less injurious angiotensin 17 (AT1 7). By binding ACE2, the SARS virus
diminishes the activity of ACE2, thereby reducing the inactivation of angiotensin II. Taken from Nicholls et al. [71] with permission.

Blockade of reninangiotensin system

activity using a reninangiotensin vaccine
Various attempts have been made to lower BP by vaccination, immunizing against components of the RAAS.
Early attempts by Michel et al. [82] to immunize against
renin lowered BP but caused an immune nephritis. More
recently, an immunotherapeutic vaccine against angiotensin I has been studied (PMD 3117) [83]. This
approach showed evidence of RAAS blockade but did
not lower BP. The AT1R has been another recent target
[84]. A key question exists regarding how to approach the
need for treatment interruption using this approach.

factor receptor transactivation, with selective inhibitors

having been developed for various specific kinase
pathways. Vasopeptidase inhibition may still find a role
despite the small incremental value of this approach
and the obvious issue of kinin-mediated adverse
effects still to be fully addressed. Finally, antisense
gene strategies and ACE2 augmentation should still
be considered experimental, but have significant
appeal as additional approaches to blockade of this
system.

References
1

Conclusion
This review summarizes further work being conducted to
enhance the efficacy and safety of blockade of the RAAS.
Whereas significant advances have been made in the
therapeutic blockade of this system using ACE inhibitors,
ARB and non-selective aldosterone receptor antagonists
there is a clear need for both additional blocking
strategies and enhancements of current therapeutic
approaches. The most advanced among these novel
approaches is blockade of the system upstream using
selective renin inhibitors as well as the greater selectivity
of aldosterone blockade using selective aldosterone
blockers such as eplerenone.
Not yet into the clinic but certainly an attractive
therapeutic target is that of angiotensin II growth

7
8

Cuspidi C, Meani S, Salerno M, Severgnini B, Fusi V, Valerio C, et al.

Cardiovascular risk stratification according to the 2003 ESHESC
guidelines in uncomplicated patients with essential hypertension:
comparison with the 1999 WHO/ISH guidelines criteria. Blood Press
2004; 13:144151.
Dzau V. The cardiovascular continuum and reninangiotensin
aldosterone system blockade. J Hypertens Suppl 2005; 23:
S9S17.
Der Sarkissian S, Huentelman MJ, Stewart J, Katovich MJ, Raizada MK.
ACE2: A novel therapeutic target for cardiovascular diseases. Prog
Biophys Mol Biol 2006; 91:163198.
Waeber B, Gavras I, Brunner HR, Cook CA, Charocopos F, Gavras HP.
Prediction of sustained antihypertensive efficacy of chronic captopril
therapy: relationships to immediate blood pressure response and control
plasma renin activity. Am Heart J 1982; 103:384390.
Ruilope LM, Rosei EA, Bakris GL, Mancia G, Poulter NR, Taddei S, et al.
Angiotensin receptor blockers: therapeutic targets and cardiovascular
protection. Blood Press 2005; 14:196209.
Abdi R, Dong VM, Lee CJ, Ntoso KA. Angiotensin II receptor blockerassociated angioedema: on the heels of ACE inhibitor angioedema.
Pharmacotherapy 2002; 22:11731175.
Frishman WH, Stier CT Jr. Aldosterone and aldosterone antagonism in
systemic hypertension. Curr Hypertens Rep 2004; 6:195200.
Menard J. The 45-year story of the development of an anti-aldosterone
more specific than spironolactone. Mol Cell Endocrinol 2004; 217:
4552.

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

34 Journal of Hypertension 2007, Vol 25 No 1

10
11

12
13

14
15

16

17

18

19

20
21

22
23
24

25

26

27

28

29

30

31
32

33

Johnston CI, Hodsman PG, Kohzuki M, Casley DJ, Fabris B, Phillips PA.
Interaction between atrial natriuretic peptide and the renin angiotensin
aldosterone system endogenous antagonists. Am J Med 1989;
87 (Suppl. 6B):24S28S.
Gerbes AL, Vollmar AM. Degradation and clearance of atrial natriuretic
factors (ANF). Life Sci 1990; 47:11731180.
Regamey F, Maillard M, Nussberger J, Brunner HR, Burnier M. Renal
hemodynamic and natriuretic effects of concomitant angiotensinconverting enzyme and neutral endopeptidase inhibition in men.
Hypertension 2002; 40:266272.
Weber MA. Vasopeptidase inhibitors. Lancet 2001; 358:1525
1532.
Corti R, Burnett JC Jr, Rouleau JL, Ruschitzka F, Luscher TF.
Vasopeptidase inhibitors: a new therapeutic concept in cardiovascular
disease? Circulation 2001; 104:18561862.
Tabrizchi R. Omapatrilat Bristol-Myers Squibb. Curr Opin Invest Drugs
2001; 2:14141422.
Packer M, Califf RM, Konstam MA, Krum H, McMurray JJ, Rouleau JL,
Swedberg K. Comparison of omapatrilat and enalapril in patients with
chronic heart failure: the Omapatrilat Versus Enalapril Randomized
Trial of Utility in Reducing Events (OVERTURE). Circulation 2002;
106:920926.
Roks A, Buikema H, Pinto YM, van Gilst WH. The reninangiotensin
system and vascular function The role of angiotensin II, angiotensinconverting enzyme, and alternative conversion of angiotensin I. Heart
Vessels 1997; 12 (Suppl.):119124.
Menard J, Campbell DJ, Azizi M, Gonzales MF. Synergistic effects of ACE
inhibition and Ang II antagonism on blood pressure, cardiac weight,
and renin in spontaneously hypertensive rats. Circulation 1997; 96:3072
3078.
Kagami S, Border WA, Miller DE, Noble NA. Angiotensin II stimulates
extracellular matrix protein synthesis through induction of transforming
growth factor-beta expression in rat glomerular mesangial cells. J Clin
Invest 1994; 93:24312437.
Nguyen G, Delarue F, Burckle C, Bouzhir L, Giller T, Sraer JD. Pivotal role of
the renin/prorenin receptor in angiotensin II production and cellular
responses to renin. J Clin Invest 2002; 109:14171427.
Oliver JA. Receptor-mediated actions of renin and prorenin. Kidney Int
2006; 69:1315.
Huang Y, Wongamorntham S, Kasting J, McQuillan D, Owens RT, Yu L,
et al. Renin increases mesangial cell transforming growth factor-beta1 and
matrix proteins through receptor-mediated, angiotensin II-independent
mechanisms. Kidney Int 2006; 69:105113.
Nguyen G, Burckle C, Sraer JD. The renin receptor: the facts, the promise
and the hope. Curr Opin Nephrol Hypertens 2003; 12:5155.
Frishman WH, Fozailoff A, Lin C, Dike C. Renin inhibition: a new approach
to cardiovascular therapy. J Clin Pharmacol 1994; 34:873880.
Wood JM, Maibaum J, Rahuel J, Grutter MG, Cohen NC, Rasetti V, et al.
Structure-based design of aliskiren, a novel orally effective renin inhibitor.
Biochem Biophys Res Commun 2003; 308:698705.
Pilz B, Shagdarsuren E, Wellner M, Fiebeler A, Dechend R, Gratze P, et al.
Aliskiren, a human renin inhibitor, ameliorates cardiac and renal damage in
double-transgenic rats. Hypertension 2005; 46:569576.
Nussberger J, Wuerzner G, Jensen C, Brunner HR. Angiotensin II
suppression in humans by the orally active renin inhibitor Aliskiren
(SPP100): comparison with enalapril. Hypertension 2002; 39:E1E8.
Gradman AH, Schmieder RE, Lins RL, Nussberger J, Chiang Y, Bedigian
MP. Aliskiren, a novel orally effective renin inhibitor, provides dosedependent antihypertensive efficacy and placebo-like tolerability in
hypertensive patients. Circulation 2005; 111:10121018.
Stanton A, Jensen C, Nussberger J, OBrien E. Blood pressure lowering in
essential hypertension with an oral renin inhibitor, aliskiren. Hypertension
2003; 42:11371143.
Jeffery S. Phase 2b/3 data promising with new renin inhibitor in
hypertension. 25 January 2005. Available at: http://www.theheart.org/
viewArticle.do?primaryKey=384775&from=/searchLayout.do. Accessed:
September 2006.
Simpson SA, Tait JF, Wettstein A, Neher R, Von Euw J, Schindler O,
Reichstein T. Konstitution des aldosterons, des neuen mineralocorticoids.
Experienta 1954; 10:132133.
Rocha R, Williams GH. Rationale for the use of aldosterone antagonists in
congestive heart failure. Drugs 2002; 62:723731.
Brilla CG, Rupp H, Funck R, Maisch B. The reninangiotensin
aldosterone system and myocardial collagen matrix remodeling in
congestive heart failure. Eur Heart J 1995; 16 (Suppl. O):107109.
Takeda Y, Miyamori I, Inaba S, Furukawa K, Hatakeyama H, Yoneda T, et al.
Vascular aldosterone in genetically hypertensive rats. Hypertension 1997;
29:4548.

34

35

36

37
38
39

40
41

42

43

44

45

46

47

48

49

50

51
52

53

54
55

56

57
58

Weber KT, Brilla CG. Pathological hypertrophy and cardiac interstitium.

Fibrosis and reninangiotensinaldosterone system. Circulation 1991;
83:18491865.
Young M, Head G, Funder J. Determinants of cardiac fibrosis in
experimental hypermineralocorticoid states. Am J Physiol 1995;
269:E657E662.
Robert V, Silvestre JS, Charlemagne D, Sabri A, Trouve P, Wassef M, et al.
Biological determinants of aldosterone-induced cardiac fibrosis in rats.
Hypertension 1995; 26:971978.
Greene EL, Kren S, Hostetter TH. Role of aldosterone in the remnant kidney
model in the rat. J Clin Invest 1996; 15:10631068.
Rudolph AE, Rocha R, McMahon EG. Aldosterone target organ protection
by eplerenone. Mol Cell Endocrinol 2004; 217:229238.
Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, et al. The
effect of spironolactone on morbidity and mortality in patients with severe
heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl
J Med 1999; 341:709717.
Delyani JA. Mineralocorticoid receptor antagonists: the evolution of utility
and pharmacology. Kidney Int 2000; 57:14081411.
Pitt B, Reichek N, Willenbrock R, Zannad F, Phillips RA, Roniker B, et al.
Effects of eplerenone, enalapril, and eplerenone/enalapril in patients with
essential hypertension and left ventricular hypertrophy: the 4E-left
ventricular hypertrophy study. Circulation 2003; 108:18311838.
Epstein M, Buckalew V Jr, Martinez F, Altamirano J, Roniker B, Kleiman J,
Krause S. Antiproteinuric efficacy of eplerenone, enalapril, and eplerenone/
enalapril combination therapy in diabetic hypertensives with
microalbuminuria. Am J Hypertens 2002; 15 (Suppl. 1):A24.
Weinberger M, MacDonald T, Conlin PR, Roniker B, Patrick JL, Krause S.
Comparison of eplerenone and losartan in patients with low-renin
hypertension. Am J Hypertens 2002; 15 (Suppl. 1):A24.
Krum H, Nolly H, Workman D, He W, Roniker B, Krause S, Fakouhi K.
Efficacy of eplerenone added to reninangiotensin blockade in
hypertensive patients. Hypertension 2002; 40:117123.
Prisant LM, Krum H, Roniker B, Krause SL, Fakouhi K, He W. Can renin
status predict the antihypertensive efficacy of eplerenone add-on therapy?
J Clin Pharmacol 2003; 43:12031210.
Williams GH, Burgess E, Kolloch RE, Ruilope LM, Niegowska J, Kipnes
MS, et al. Efficacy of eplerenone versus enalapril as monotherapy in
systemic hypertension. Am J Cardiol 2004; 93:990996.
Weinberger MH, White WB, Ruilope LM, MacDonald TM, Davidson RC,
Roniker B, et al. Effects of eplerenone versus losartan in patients with
low-renin hypertension. Am Heart J 2005; 150:426433.
White WB, Duprez D, St Hillaire R, Krause S, Roniker B, Kuse-Hamilton J,
Weber MA. Effects of the selective aldosterone blocker eplerenone versus
the calcium antagonist amlodipine in systolic hypertension. Hypertension
2003; 41:10211026.
White WB, Carr AA, Krause S, Jordan R, Roniker B, Oigman W.
Assessment of the novel selective aldosterone blocker eplerenone using
ambulatory and clinical blood pressure in patients with systemic
hypertension. Am J Cardiol 2003; 92:3842.
Flack JM, Oparil S, Pratt JH, Roniker B, Garthwaite S, Kleiman JH, et al.
Efficacy and tolerability of eplerenone and losartan in hypertensive black
and white patients. J Am Coll Cardiol 2003; 41:11481155.
Williams GH. Aldosterone biosynthesis, regulation, and classical
mechanism of action. Heart Fail Rev 2005; 10:713.
Heymes C, Garnier A, Fuchs S, Bendall JK, Nehme J, Ambroisine ML,
et al. Aldosterone-synthase overexpression in heart: a tool to
explore aldosterones effects. Mol Cell Endocrinol 2004; 217:
213219.
Sadoshima J, Izumo S. Molecular characterization of angiotensin II-induced
hypertrophy of cardiac myocytes and hyperplasia of cardiac fibroblasts.
Critical role of the AT1 receptor subtype. Circ Res 1993; 73:413
423.
Egido J. Vasoactive hormones and renal sclerosis. Kidney Int 1996;
49:578597.
Geisterfer AA, Peach MJ, Owens GK. Angiotensin II induces hypertrophy,
not hyperplasia, of cultured rat aortic smooth muscle cells. Circ Res 1988;
62:749756.
Guh JY, Yang ML, Yang YL, Chang CC, Chuang LY. Captopril reverses
high-glucose-induced growth effects on LLC-PK1 cells partly by
decreasing transforming growth factor-beta receptor protein expressions.
J Am Soc Nephrol 1996; 7:12071215.
Hahn AW, Kern F, Buhler FR, Resink TJ. The reninangiotensin system and
extracellular matrix. Clin Invest 1993; 71 (5 Suppl.):S7S12.
Ruiz-Ortega M, Gomez-Garre D, Alcazar R, Palacios I, Bustos C,
Gonzalez S, et al. Involvement of angiotensin II and endothelin in
matrix protein production and renal sclerosis. J Hypertens 1994; 12
(Suppl.):S51S58.

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Novel inhibitors of the RAAS Krum and Gilbert 35

59

60

61

62

63

64

65

66

67

68
69

70

71
72

73

74

75

76

77

78

79
80

81

Murasawa S, Mori Y, Nozawa Y, Gotoh N, Shibuya M, Masaki H, et al.

Angiotensin II type 1 receptor-induced extracellular signal-regulated
protein kinase activation is mediated by Ca2/calmodulin-dependent
transactivation of epidermal growth factor receptor. Circ Res 1998;
82:13381348.
Eguchi S, Numaguchi K, Iwasaki H, Matsumoto T, Yamakawa T,
Utsunomiya H, et al. Calcium-dependent epidermal growth factor receptor
transactivation mediates the angiotensin II-induced mitogen-activated
protein kinase activation in vascular smooth muscle cells. J Biol Chem
1998; 273:88908896.
Heeneman S, Haendeler J, Saito Y, Ishida M, Berk BC. Angiotensin II
induces transactivation of two different populations of the platelet-derived
growth factor beta receptor key role for the adaptor protein Shc. J Biol
Chem 2000; 275:1592615932.
Linseman DA, Benjamin CW, Jones DA. Convergence of angiotensin II and
platelet-derived growth factor receptor signaling cascades in vascular
smooth muscle cells. J Biol Chem 1995; 270:1256312568.
Lautrette A, Li S, Alili R, Sunnarborg SW, Burtin M, Lee DC, et al.
Angiotensin II and EGF receptor cross-talk in chronic kidney diseases:
a new therapeutic approach. Nat Med 2005; 11:867874.
Wolf G. As time goes by: angiotensin II-mediated transactivation of the
EGF receptor comes of age. Nephrol Dial Transplant 2005; 20:2050
2053.
Wassef L, Kelly DJ, Gilbert RE. Epidermal growth factor receptor inhibition
attenuates early kidney enlargement in experimental diabetes. Kidney Int
2004; 66:18051814.
Eskildsen-Helmond YE, Mulvany MJ. Pressure-induced activation of
extracellular signal-regulated kinase 1/2 in small arteries. Hypertension
2003; 41:891897.
Kelly DJ, Cox AJ, Gow RM, Zhang Y, Kemp BE, Gilbert RE. Platelet-derived
growth factor receptor transactivation mediates the trophic effects of
angiotensin II in vivo. Hypertension 2004; 44:195202.
Jain RK, Booth MF. What brings pericytes to tumor vessels? J Clin Invest
2003; 112:11341136.
Druker BJ, Tamura S, Buchdunger E, Ohno S, Segal GM, Fanning S, et al.
Effects of a selective inhibitor of the Abl tyrosine kinase on the growth of
Bcr-Abl positive cells. Nat Med 1996; 2:561566.
Donoghue M, Hsieh F, Baronas E, Godbout K, Gosselin M, Stagliano N,
et al. A novel angiotensin-converting enzyme-related carboxypeptidase
(ACE2) converts angiotensin I to angiotensin 19. Circ Res 2000; 87:
E1E9.
Nicholls J, Peiris M. Good ACE, bad ACE do battle in lung injury, SARS.
Nat Med 2005; 11:821822.
Vickers C, Hales P, Kaushik V, Dick L, Gavin J, Tang J, et al. Hydrolysis of
biological peptides by human angiotensin-converting enzyme-related
carboxypeptidase. J Biol Chem 2002; 277:1483814843.
Crackower MA, Sarao R, Oudit GY, Yagil C, Kozieradzki I, Scanga SE, et al.
Angiotensin-converting enzyme 2 is an essential regulator of heart function.
Nature 2002; 417:822828.
Santos RA, Ferreira AJ, Nadu AP, Braga AN, de Almeida AP, CampagnoleSantos MJ, et al. Expression of an angiotensin-(1-7)-producing fusion
protein produces cardioprotective effects in rats. Physiol Genom 2004;
17:292299.
Huang L, Sexton DJ, Skogerson K, Devlin M, Smith R, Sanyal I, et al. Novel
peptide inhibitors of angiotensin-converting enzyme 2. J Biol Chem 2003;
278:1553215540.
Dales NA, Gould AE, Brown JA, Calderwood EF, Guan B, Minor CA, et al.
Substrate-based design of the first class of angiotensin-converting
enzyme-related carboxypeptidase (ACE2) inhibitors. J Am Chem Soc
2002; 124:1185211853.
Imai Y, Kuba K, Rao S, Huan Y, Guo F, Guan B, et al. Angiotensinconverting enzyme 2 protects from severe acute lung failure. Nature 2005;
436:112116.
Huentelman MJ, Grobe JL, Vazquez J, Stewart JM, Mecca AP, Katovich MJ,
et al. Protection from angiotensin II-induced cardiac hypertrophy and
fibrosis by systemic lentiviral delivery of ACE2 in rats. Exp Physiol 2005;
90:783790.
Raizada MK, Der Sarkissian S. Potential of gene therapy strategy for the
treatment of hypertension. Hypertension 2006; 47:69.
Yoneda M, Sanada H, Yatabe J, Midorikawa S, Hashimoto S, Sasaki M,
et al. Differential effects of angiotensin II type-1 receptor antisense
oligonucleotides on renal function in spontaneously hypertensive rats.
Hypertension 2005; 46:5865.
Klett CP, Anderson D, Sholook M, Granger JP. Antisense
oligodeoxynucleotides directed against a novel angiotensinogen
mRNA-stabilizing protein reduce blood pressure in spontaneously
hypertensive rats. Am J Physiol Regul Integr Comp Physiol 2004;
287:R619R626.

82

83

84

Michel JB, Galen FX, Guettier C, Sayah S, Hinglais N, Fehrentz JA, et al.
Immunological approach to blockade of the renin-substrate reaction.
J Hypertens Suppl 1989; 7:S63S70.
Brown MJ, Coltart J, Gunewardena K, Ritter JM, Auton TR, Glover JF.
Randomized double-blind placebo-controlled study of an angiotensin
immunotherapeutic vaccine (PMD3117) in hypertensive subjects. Clin Sci
(Lond) 2004; 107:167173.
Zhu F, Liao YH, Li LD, Cheng M, Wei F, Wei YM, Wang M. Target organ
protection from a novel angiotensin II receptor (AT1) vaccine ATR12181 in
spontaneously hypertensive rats. Cell Mol Immunol 2006; 3:107114.

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.