Bradykinin : a contribution to blood pressure reduction with ACE inhibition in man?

Angiotensin II-converting enzyme (ACE) inhibitors have an established role in the treatment of hypertension and heart failure. These drugs not only prevent the conversion of angiotensin I to angiotensin II (All) but, by inhibition of kininase II, they modify the metabolism of several other vasoactive substances. There is good evidence that the inactivation of bradykinin (BK) is blocked by ACE inhibitors resulting in enhanced effects of circulating and tissue BK. There has been considerable controversy as to whether BK contributes to any of the beneficial or unwanted actions of ACE inhibitors. The availability of potent selective antagonists of bradykinin B 2 subtype receptors offers an experimental approach to explore the contribution of BK in man. The B 2 receptor is responsible for the cardiovascular effects of BK in man. Icatibant acetate (HOE 140) has been used by ourselves and by others in controlled trials in normotensive males on a normal salt intake in salt-depleted normotensives and hypertensives. In both studies, icatibant was given by intravenous infusion with or without an ACE inhibitor. Both studies concluded that the BK antagonist significantly attenuated the acute fall in blood pressure after ACE inhibitor administration. Our study employed a double-blind design with ACE inhibition induced by intravenous perindoprilat (active metabolite of perindopril). Combined B 2 antagonism and ACE inhibition significantly reduced the mean maximum fall in blood pressure over the first 3 h after ACE inhibitor administration as well as the area under the blood pressure/ time curve compared with ACE inhibition alone. Icatibant alone caused a small, but significant, increase in blood pressure compared with placebo. In our study, coadministration did not influence inhibition of plasma ACE or the reactive rise in active renin concentration when compared with an ACE inhibitor alone. These studies in man suggest that at least part of the acute blood pressure lowering action of an ACE inhibitor is due to an interaction with bradykinin B 2 mechanisms. The results are consistent with experimental studies in vivo and with in vitro studies which implicate BK in endothelial function and vasodilatation by activation of nitric oxide and release of prostaglandins. The long-term importance of BK mechanisms in blood pressure reduction remains to be determined as do the implications of these findings to the beneficial effects of ACE inhibitors on outcome in patients with cardiovascular disease.