Abstract Angiotensin Converting Enzyme Research Articles

Polypharmacy in chronic heart failure: practical issues regarding the use of angiotensin-converting enzyme inhibitors, beta-blockers and other drugs

Angiotensin-converting enzyme (ACE) inhibitors and betablockers are the cornerstone for treatment of patients with chronic heart failure (CHF), and are usually combined with diuretics, with or without digoxin. With the development of new, additional treatments, the problem of polypharmacy becomes relevant, and strategies to individualize treatment are warranted. This review considers optimal drug treatment in patients with CHF, focusing on the possible problems that can occur when combining drugs. A hierarchy of drugs is suggested, starting from the assumption of a central role for early and widespread use of ACE inhibitors and beta-blockers. A model of drug therapy is proposed that is based on each patient's individual clinical and genetic considerations, which might serve to further optimize treatment.

Vasopeptidase inhibition: effective blood pressure control for vascular protection.

Angiotensin converting enzyme (ACE) inhibition is a well-established principle in the treatment of hypertension, and numerous large scale clinical studies have clearly demonstrated the beneficial effects of inhibiting the renin-angiotensin-aldosterone system (RAS) in hypertension. The clinical success of ACE inhibitors encouraged attempts to inhibit other key enzymes in the regulation of vascular tone, such as the neutral endopeptidase (NEP). Similar to ACE, NEP is an endothelial cell surface metalloproteinase, which is involved in the degradation of several regulatory peptides including the natriuretic peptides, and augments vasodilatation and natriuresis through increased levels of atrial natriuretic peptide. By inhibiting the RAS and potentiating the natriuretic peptide system at the same time, combined NEP/ACE inhibitors, the so-called "vasopeptidase inhibitors," reduce vasoconstriction and enhance vasodilatation, and in turn decrease peripheral vascular resistance and blood pressure. Within the vessel wall this may lead to a reduction of vasoconstrictor and proliferative mediators such as angiotensin II and endothelin-1, and may increase local levels of bradykinin as well as natriuretic peptides. Based on these considerations, numerous preclinical studies with vasopeptidase inhibitors have been performed and reveal promising results in experimental hypertension. Correspondingly, large-scale clinical studies in patients with hypertension are on the way, to transfer the principle of vasopeptidase inhibition from bench to bedside.

The renin-angiotensin system: a review of trials with angiotensin-converting enzyme inhibitors and angiotensin receptor blocking agents

Angiotensin-converting enzyme (ACE) inhibitors have been very successful in patients with vascular disease, in particular for hypertension, left ventricular dysfunction and vascular protection. Angiotensin receptor blocking drugs (ARBs) were developed later and differ from ACE inhibitors in several ways. We are now beginning to see the results of large studies of ARBs in high-risk patients and some head-to-head comparisons between these two classes of drugs which reduce the actions of angiotensin II. This review considers these trials under the headings of heart failure, hypertension, renal function, and high-risk cardiovascular disease/coronary heart disease.

The role of angiotensin-converting enzyme inhibitors in the treatment of hypertension.

Angiotensin-converting enzyme (ACE) inhibitors continue to find new uses. The Heart Outcomes Prevention Evaluation study has demonstrated their wide application as a preventive measure for patients at high risk of cardiovascular disease, but the available clinical trials in hypertensive subjects do not so far suggest any clear superiority over conventional treatment. The available trials may have been underpowered to detect non-blood pressure-related benefits on smooth muscle growth, endothelial function, left ventricular hypertrophy, and plaque rupture, when used in relatively low-risk subjects with uncomplicated hypertension. Clinical trials have also shown that two or more drugs are needed to lower blood pressure even to 140/90. Few patients have uncomplicated hypertension, so the choice of their drugs will be powerfully influenced by their other clinical problems. Nevertheless, there is a strong case for an attack on the renin-angiotensin system. Whether this will be by ACE inhibition, angiotensin-II receptor blockade, or both, is the subject of current clinical trials.

Diabetic microalbuminuria delayed by ACE inhibitor

Angiotensin-converting enzyme (ACE) inhibitors are already known to slow the development of overt diabetic nephropathy in patients with type 2 diabetes mellitus (T2DM) with hypertension or in normotensive patients with T1DM. However, the effectiveness of other antihypertensive drugs has not been fully clarified. A recent comparison of perindopril, an ACE inhibitor, with nifedipine, a calcium-channel blocker, has shown that perindopril was more effective at slowing the progression of this condition in normotensive diabetics.Writing in the American Journal of Kidney Disease (May issue), George Jerums (University of Melbourne, VIC, Australia) and colleagues compared the results of 36 months of treatment with either perindopril or nifedipine of 33 normotensive patients with T1DM. Whereas there was no difference in mean arterial pressure, or changes in the levels of cholesterol, triglyceride or glycosylated hemoglobin between the two groups, albumin excretion rates (AER) progressively increased in both the nifedipine and placebo groups (reaching a median of 122 μg min−1 and 112 μg min−1 respectively) and declined in most of the patients receiving perindopril (a median of 23 μg min−1 was recorded).Compared with the four nifedipine-treated and three placebo-treated patients, only one perindopril-treated patient developed macroalbuminuria. Seven perindopril-treated patients regressed to normoalbuminuria compared with none of the other patients.That the use of an ACE inhibitor was more effective than were dihydropyridine calcium-channel blockers in slowing the long-term progression of albuminuria suggests that ACE inhibitors should be used as treatment for normotensive microalbuminuric patients with T1DM. However, Jerums et al. are quick to caution whether such functional effects of ACE inhibition are associated with protective effects on renal structure. LS

EFFECT OF CHRONIC TREATMENT WITH LOSARTAN ON STREPTOZOTOCIN INDUCED DIABETIC NEPHROPATHY

Angiotensin converting enzyme (ACE) inhibitors produce a number of beneficial effects in a condition where diabetes - mellitus and hypertension co-exist. The present investigation was undertaken to study the effect of chronic treatment with losartan (2mg/kg, p.o.) on streptozotocin(STZ)-induced (45mg/kg, single dose, tail vein) diabetic nephropathy in rats. Treatment of ratswith STZ produced a significant loss of body weight, polyuria, polydipsia, hypoinsulinemia, hyperglycemia and increase in blood pressure. There was a significant increase in blood glucose levels in STZ-diabetic rats. Serum cholesterol, creatinine, urea and blood urea nitrogen (BUN) levels were found to be increased significantly in the STZ group diabetic rats. Treatment with losartan significantly prevented the raise in cholesterol, creatinine, urea and blood urea nitrogen levels. Creatinine clearance was significantly less in STZ-diabetic rats as compared to control animals and treatment with losartan significantly increased creatinine clearence. Our data suggest a beneficial effect of losartan in STZ - induced nephropathy in rats.

Angiotensin converting enzyme DD genotype affects the changes of plasma plasminogen activator inhibitor-1 activity after primary percutaneous transluminal coronary angioplasty in acute myocardial infarction patients.

Angiotensin converting enzyme (ACE) DD genotype, and plasminogen activator inhibitor (PAI-1) 4G/4G genotype have been reported to affect PAI-1 activity in control subjects and atherosclerotic patients, but no data are available on the influence of angiotensin II type 1 receptor (AT1R) A1166C polymorphism on the inhibitor levels. The degree of fibrinolytic activation after percutaneous transluminal coronary angioplasty (PTCA) has been found to affect the risk of restenosis. The aim of this study was to investigate the possible influence of ACE I/D, AT1R A1166C, and PAI-1 4G/5G polymorphisms on the changes of PAI-1 activity after primary successful percutaneous transluminal angioplasty. In 29 consecutive acute myocardial infarction patients, undergoing primary successful angioplasty, genotyping of ACE I/D, AT1R A1166C, and PAI-1 4G/5G polymorphisms was performed by polymerase chain reaction and restriction fragment length polymorphism analysis, and PAI-1 plasma activity (chromogenic method) was assessed before and after angioplasty. Following angioplasty, PAI-1 activity increased in 10 of 29 patients and decreased or remained unchanged in 19 of 29. ACE DD genotype was significantly (P = 0.04) associated with an increase of PAI-1 activity post angioplasty (OR DD/ID+II = 6.5, CI 95% 4.83-8.22). Whereas no effect of PAI-1 4G/5G and AT1R A1166C polymorphisms on PAI-1 response to angioplasty was demonstrated, these data suggest that renin-angiotensin system genes are involved in the regulation of the fibrinolytic response to balloon injury, possibly affecting angiotensin converting enzyme activity. This interaction between the renin-angiotensin system and hemostasis may be a mechanism by which ACE DD genotype affects the risk of restenosis after percutaneous transluminal angioplasty.

Pulmonary angiotensin-converting enzyme (ACE) binding and inhibition in humans. A positron emission tomography study.

Angiotensin-converting enzyme (ACE) inhibition attenuates pulmonary hypertension and delays the development of pulmonary vascular remodeling in animal models. Thus, ACE inhibition might be a useful treatment for primary pulmonary hypertension (PPH). To determine the dose of ACE inhibitor required to specifically block pulmonary ACE in humans, we measured the combined forward rate constant (CFRC) for [(18)F]-fluorocaptopril, which is proportional to the mass of ACE in the lung, using positron emission tomography (PET). In five normal subjects, CFRC was measured twice, 1 wk apart, to assess measurement reproducibility. The CFRC was 0.151 +/- 0.067 for the first measurement and 0.140 +/- 0.060 for the second measurement (p = not significant [NS]). In five normals, CFRC decreased on average 84%, from 0.177 +/- 0.053/s to 0.028 +/- 0.017/s (p < 0.05), after 1 wk ingestion of 5 mg enalapril orally once a day (the scans were performed 24 h after the last medication). Similarly, in five patients with PPH, CFRC decreased on average 76%, from 0.052 +/- 0. 020/s to 0.012 +/- 0.003 (p < 0.01), after 1 wk enalapril, despite much lower baseline values. We conclude that the total mass of pulmonary ACE appears to be significantly reduced in PPH and that only low doses of ACE inhibitors may be needed to block the effects of ACE on vascular remodeling in PPH.

Will more complete inhibition of the RAAS with angiotensin receptor blockade improve survival following myocardial infarction?

Angiotensin-converting enzyme (ACE) inhibitors have a well-established role in the management of patients with hypertension, diabetes, heart failure and myocardial infarction (MI). ACE inhibitors have been particularly well studied in acute and chronic MI with consistent and substantial survival benefits demonstrated, particularly in the higher risk groups. The recent development of angiotensin II (Ang II) receptor blockers (ARBs) as a well tolerated pharmacological therapy to more completely inhibit the actions of Ang II at the AT1-receptor level raises questions concerning comparative efficacy with the proven ACE inhibitor experience. Two major trials will provide a direct comparison of ARBs with an ACE inhibitor. The Valsartan in Acute Myocardial Infarction (VALIANT) trial is specifically designed to compare and contrast the ARB, valsartan, used both alone as well as in combination with a proven ACE inhibitor regimen, in a high risk MI population. VALIANT, with its three arms targetting 14,500 patients, is uniquely poised to determine whether the pharmacological advance in the development of ARBs confers additional clinical (survival) value in high risk MI patients.

Imidapril, an angiotensin-converting enzyme inhibitor, improves insulin sensitivity by enhancing signal transduction via insulin receptor substrate proteins and improving vascular resistance in the Zucker fatty rat.

Angiotensin-converting enzyme (ACE) inhibitors are antihypertensive agents, that inhibit the conversion of angiotensin I to angiotensin II, resulting in smooth-muscle relaxation and a reduction of vascular resistance. Recently, it has been suggested that ACE inhibitors improve insulin resistance in diabetic patients. To investigate the effect of an ACE inhibitor on insulin sensitivity, insulin signaling, and circulation, imidapril was administered orally or intraduodenally to Zucker fatty rats. Oral administration of imidapril improved insulin sensitivity based on the results of an oral glucose tolerance test (OGTT) and a decrease in urinary glucose secretion. Phosphatidylinositol 3-kinase (PI 3-kinase) activity associated with hepatic insulin receptor substrate-1 (IRS-1) in the insulin-stimulated condition was significantly enhanced 110% without a significant alteration in tyrosine phosphorylation of IRS-1 in the imidapril-treated group. In muscle, IRS-1 tyrosine phosphorylation and PI 3-kinase activity associated with IRS-1 in the insulin-stimulated condition were enhanced 70% and 20%, respectively, in the imidapril-treated group. In contrast, an alteration of the IRS-2 pathway was observed only in liver; a significant insulin-induced increase in the IRS-2-associated PI 3-kinase over the basal level was observed in the imidapril-treated group but not in the control. In addition, treatment with imidapril was shown to significantly reduce blood pressure and increase blood flow in the liver and muscle. These results suggest that the ACE inhibitor imidapril may improve insulin sensitivity not only by acting directly on the insulin signaling pathway but also by increasing blood flow in tissues via normalization of vascular resistance, a major cause of hypertension.

Summary of Randomized Trials of Angiotensin Converting Enzyme Inhibitors

Angiotensin converting enzyme (ACE) inhibitors have been shown to reduce the risk of death, worsening heart failure and recurrent infarction in patients with left ventricular dysfunction and heart failure. They have also been shown to reduce mortality in the acute phase of myocardial infarction. They have been demonstrated to reduce major vascular events and progression of renal disease in diabetes with hypertension, compared to placebo and to calcium channel blockers. Current trials are evaluating their role in preventing major vascular events in patients with coronary artery disease, strokes and Type II diabetes who are normotensive.

Angiotensin II type 1 receptor blockade with candesartan protects the porcine myocardium from reperfusion-induced injury.

Angiotensin-converting enzyme (ACE) inhibitors reduce myocardial ischemia/reperfusion injury. It is unclear whether reduced formation of angiotensin II or attenuated degradation of bradykinin is responsible for the beneficial effects. We investigated the role of endogenous angiotensin II in ischemia/reperfusion injury by studying the effects of the angiotensin II type 1 receptor antagonist candesartan on myocardial function, infarct size, and perfusion after ischemia/reperfusion. Anesthetized pigs were subjected to 45 min of regional ischemia and 240 min of reperfusion. Starting 5 min before reperfusion, four groups of pigs (n = 6 in each) received coronary venous retroinfusion of candesartan (0.2, 2, or 20 microg/kg) or vehicle for 30 min. Myocardial regional blood flow was measured with radioactive microspheres in two separate groups (n = 6 in each) given 20 microg/kg candesartan or vehicle. Retroinfusion of 20 microg/kg of candesartan improved recovery of left ventricular systolic segment shortening measured by sonomicrometry in the ischemic area compared with 0.2 microg/kg of candesartan and vehicle. Infarct size, as a percentage of the area at risk, was smaller in the 2 and 20 microg/kg groups than in the vehicle group (39.1 +/- 11.6% and 34.8 +/- 10.2% vs. 78.3 +/- 8.9%, p < 0.01). There was no difference between candesartan and vehicle in their effects on regional myocardial blood flow. Angiotensin II type 1 receptor blockade supports myocardial functional recovery and reduces infarct size. This effect is not related to improved regional myocardial blood flow during reperfusion.

Emerging concepts: angiotensin-converting enzyme inhibition in coronary artery disease.

Angiotensin-converting enzyme (ACE) inhibitors have played a highly beneficial role in the therapy of hypertension and congestive heart failure. Detailed analysis of some of the heart failure trials in patients with these diseases has uncovered unexpected benefits in the prevention of cardiovascular events. Paralleling these observations are the rapidly accruing basic studies describing important molecular and cellular effects of these agents. For example, ACE inhibition will prevent stimulation of smooth muscle cell angiotensin II receptors, thereby blocking both contractile and proliferative actions. In addition, ACE inhibition of kininase II inhibits the breakdown of bradykinin. Bradykinin is a direct stimulant of nitric oxide release from the intact endothelial cell. Thus, at the cellular level ACE inhibition shifts the balance of ongoing mechanisms in favor of those promoting vasodilatory, antiaggregatory, antithrombotic, and antiproliferative effects. These effects underlie the potential benefits of ACE inhibition in the therapy of coronary artery disease and atherosclerosis.

Angiotensin II formation in dog heart is mediated by different pathways in vivo and in vitro

Angiotensin-converting enzyme (ACE) inhibitors (I) have beneficial effects that are presumably mediated by decreased angiotensin II (ANG II) production. However, in vitro assays in human heart extracts have demonstrated that > 75% of ANG II-forming enzyme activity was not inhibited by captopril (Cap) and therefore did not appear to be related to ACE but was inhibited by chymostatin, suggesting that it was predominantly chymase-like activity. Previous work in our laboratory has demonstrated a similar relative contribution of ACE and chymase-like activity toward ANG II formation in vitro in dog heart tissue extracts. Accordingly, we compared Cap-inhibitable ANG II formation in vitro in heart tissue of five adult mongrel dogs to the in vivo Cap-inhibitable, ANG II-forming activity across the myocardial bed in four openchest, adult mongrel dogs. In vitro studies demonstrated that only 6 +/- 2% of ANG II formation was inhibited by Cap from heart tissue extracts of the left ventricular midwall. In in vivo studies, ANG I (0.5 nmol/min) followed by ANG I plus the ACE inhibitor Cap (0.1 mumol/min) was infused into the left anterior descending artery, and ANG II was assayed in the proximal aorta and coronary sinus. The arterial-venous (A-V) difference of ANG II across the myocardial circulation increased significantly during ANG I infusion (-13.4 +/- 23.5 to 142.8 +/- 71.4 pg/ml; P < 0.03). Subsequent coinfusion of Cap with ANG I significantly decreased the myocardial A-V difference of ANG II by 60 +/- 18% (P < 0.05). Thus, in contrast to the in vitro situation, ANG II formation in vivo is inhibited significantly by Cap in the normal dog heart. This comparison of in vivo and in vitro conversion of ANG I to ANG II by ACE and chymase-like activity suggests that in vitro assays may underestimate the functional contribution of ACE to intracardiac ANG II formation.

Angiotensin II Receptor Antagonists in the Prevention of Radiation Nephropathy

Angiotensin-converting enzyme (ACE) inhibitors can be used to prevent the development of radiation nephropathy. Current studies were designed to determine whether blocking the angiotensin II (AII) receptor, rather than preventing the creation of AII, would be effective in the prophylaxis of radiation nephropathy. Rats received 17 Gy total-body irradiation (TBI) in six fractions followed by syngeneic bone marrow transplantation (BMT). Prior to TBI the rats were randomized to groups receiving an ACE inhibitor (captopril), an AII type 1 (AT1) receptor antagonist (L-158,809) or no treatment. Renal function was assessed over 40 weeks, and a subset of animals were sacrificed for histopathology at 33 weeks. Renal function deteriorated progressively in animals receiving TBI alone, leading to renal failure by 34 weeks. Renal function was significantly better in animals receiving either captopril or L-158,809, and none of these animals had progressed to renal failure by 43 weeks. Analysis of both renal function and histopathology shows that the AII receptor antagonist is more effective than the ACE inhibitor in the prophylaxis of BMT nephropathy. This indicates that a reduction of activation of the AT1 receptor by AII, by itself, is sufficient for the prophylaxis of radiation nephropathy.

Angiotensin converting enzyme inhibitory pentapeptide isolated from supernatant of pig plasma treated by trichloroacetic acid

Angiotensin converting enzyme (ACE) inhibitory peptide was isolated from supernatant of trichloroacetic acid treated pig plasma using gel filtration chromatography and reverse phase high pressure liquid chromatography. Protein sequencing showed that the peptide is a pentapeptide of Gly-Val-His-Gly-Val with 2 μM as IC50 value.

NO synthesis is involved in structural and functional effects of ACE inhibitors in injured arteries.

Angiotensin-converting enzyme (ACE) inhibitors reduce intimal hyperplasia after balloon injury. A role for nitric oxide (NO) has been suggested in this effect. Because recent data suggest that NO may modulate some features of endothelial cells and because endothelial cells are involved in the control of intimal hyperplasia, we investigated the role of NO synthesis in the effect of an ACE inhibitor, perindopril, on neoendothelial dysfunction and intimal hyperplasia in a rabbit model of unilateral iliac balloon injury. New Zealand White male rabbits received placebo, perindopril, or cotreatment with perindopril and NG-nitro-L-arginine methyl ester (L-NAME) and were evaluated 4 wk after the injury. Fifteen rabbits (5 in each group) were used to assess in vitro vasoreactivity and twenty-four (8 in each group) for morphometric analysis. In injured vessels, neoendothelium-dependent relaxation in ACE inhibitor-treated animals was improved compared with placebo (P < 0.05) and restored to the level of noninjured vessels (NS). The improvement observed with ACE inhibitor was abolished by cotreatment with L-NAME (P < 0.05). In the same vessels, no effect was observed on neoendothelium-independent vasoreactivity. The improved neoendothelial dysfunction with ACE inhibitor was associated with a 66% reduction in intimal thickening (P < 0.01). The effect was also reversed by cotreatment with L-NAME (P < 0.01). In noninjured vessels, treatment did not alter vasoreactivity or morphology of the vessel wall. These results suggest that NO synthesis may play a key role in the improvement of vascular function seen with ACE inhibitor in balloon-injured vessels.

A Comparative Study of Captopril and Enalapril on Endothelial Cell Function in Congestive Heart Failure Patients

Angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce the incidence of future coronary artery thromboses in postmyocardial infarction patients. A possible prothrombotic role for the angiotensin system has been postulated, and support for this has been provided by a recent study that demonstrated that an infusion of angiotensin increases levels of the prothrombotic plasminogen activator inhibitor (PAI). In the current study the authors have investigated the effect of two ACE inhibitors, captopril and enalapril, on tissue plasminogen activator (tPA) and PAI in 33 congestive heart failure (CHF) patients. Blood samples were obtained pretreatment and then at weeks 1, 12, and 24 after initiation of ACE inhibitor therapy for measurement of tPA antigen and PAI activity levels. The results of the study indicated that the initiation of ACE inhibitors had no significant effects on tPA antigen or PAI activity levels at the time points studied, and no significant differences were demonstrated between captopril and enalapril. The results suggest, therefore, that ACE inhibitors do not affect tPA antigen or PAI activity in CHF patients, and thus another mechanism is probably responsible for the observed decrease in coronary artery thromboses in post-MI patients treated with ACE inhibitors.

The effects of ACE inhibition on ischemic cardiac events: Pump failure, reinfarction, hospitalization for angina, and ventricular tachyarrhythmias

Angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce the incidence of mortality following myocardial infarction (MI) and to have beneficial effects on the consequences of MI. Various studies, including several large-scale trials such as ISIS-4, GISSI-3, SAVE, AIRE, and SOLVD, have demonstrated the beneficial effects of ACE inhibitors on mortality and morbidity after both early (up to 48 h post-MI) and late (weeks to months post-MI) intervention. Morbidity benefits include reduced incidences of heart failure, unstable angina, and reinfarction, although the latter two effects may not become evident until 9 and 18 months, respectively, after treatment initiation. These effects are independent of dose used, and a class effect of ACE inhibitors seems likely. Finally, a primary advantage of using ACE inhibitors in patients with cardiac disease is shown by the substantial savings which can be achieved, particularly in terms of reduced need for hospitalization for reinfarction, unstable angina and heart failure. In addition to their proven mortality benefits in acute MI, ACE inhibitors reduce heart failure and/or left ventricular dysfunction. Benefit accrues whether treatment is initiated early or late.

Glucocorticoids Induce Angiotensin-Converting Enzyme Expression in Vascular Smooth Muscle

Angiotensin-converting enzyme (ACE) activity plays a central role in vessel growth and remodeling as shown by the fact that ACE inhibitors reduce neointimal proliferation after rat carotid injury. To investigate the mechanisms that regulate smooth muscle cell ACE expression, we studied the effects of steroids on ACE activity and mRNA in cultured rat aortic smooth muscle cells. ACE activity was present at low levels independent of growth state. In response to the glucocorticoid dexamethasone (100 nmol/L for 72 hours), ACE activity (hydrolysis of [3H]benzoyl-Phe-Ala-Pro) increased 10.1 +/- 3.1-fold. The increase in activity occurred within 12 hours and peaked after 72 hours of treatment. The increase in ACE activity was specific for glucocorticoids and paralleled their potency (dexamethasone > hydrocortisone = prednisolone). Dexamethasone increased the steady-state level of ACE mRNA in a concentration-dependent manner (21.4 +/- 0.4-fold at 100 nmol/L for 72 hours). Dexamethasone stimulation of ACE expression appeared to be due to both increased transcription and stabilization of ACE enzyme mRNA. This was suggested by the finding that dexamethasone stimulated nuclear run-on expression of ACE mRNA by only threefold, in contrast to the 21-fold increase in steady-state mRNA. These findings establish that ACE is a dynamically regulated enzyme in rat aortic smooth muscle cells. In addition, the present findings suggest an important role for stress steroids in the vascular response to injury in vivo.