P ulmonary arterial hypertension (PAH) is a fatal disease characterized by increased pulmonary vascular resistance, leading to right heart failure and death.1,2 Increased pulmonary vascular resistance is caused by distal pulmonary vascular remodeling, including prolonged vasoconstriction, proliferation and migration of vascular smooth muscle cells (VSMCs), and endothelial injury.3 Although multiple pharmacological agents, such as vasodilators and anticoagulants, have been developed for the treatment of PAH, long-term prognosis of patients with severe PAH remains poor because of progressive right heart failure. 3 Thus, more effective treatments need to be urgently developed.Rho-kinase (ROCK) belongs to the serine/threonine kinases family and is an important downstream effector of the small GTP-binding protein RhoA. It has been demonstrated that Rho/ROCK pathway plays an important role in various fundamental cellular functions, including contraction, motility, proliferation, and migration, leading to the development of cardiovascular diseases, including PAH. 4,5 There are 2 isoforms of ROCK: ROCK1 (Rho-kinase β) and ROCK2 (Rho-kinase α).6 ROCK1 and ROCK2 are highly homologous, sharing 65% homology in amino acid sequence and 92% homology in their kinase domains. 6 Both isoforms are ubiquitously expressed in invertebrates and vertebrates with ROCK1 expressed mainly in circulating inflammatory cells and ROCK2 in VSMC. 7,8 Homozygous ROCK1-deficient mice show open eyelids at birth and omphalocele, whereas homozygous ROCK2-deficient mice die embryonically because of placental dysfunction, 9,10 suggesting that ROCK1 and ROCK2 mediate different functions in different types of cells.We have previously reported that a long-term treatment with an isoform-nonspecific ROCK inhibitor, fasudil, suppresses the development of monocrotaline-induced and hypoxia-induced pulmonary hypertension (PH) in animal models.11,12 Furthermore, we have recently obtained a direct evidence for increased ROCK activation in patients with idiopathic PAH (IPAH). 13 However, although isoform-nonspecific ROCK inhibitors were effective in previous studies of PAH in both animals and humans, 14 the particular isoform of ROCK responsible for the effect has not been evaluated.It was previously reported that heterozygous ROCK1-deficient mice had decreased neointima formation after carotid artery ligation associated with reduced leukocytemediated inflammation. 15 Thus, ROCK1 seems to play an important role in circulating inflammatory cells in the pathogenesis of vascular diseases. 7,8 In contrast, Rho/ROCK2 pathway plays a central role in VSMC-mediated vasoconstriction © 2013 American Heart Association, Inc. Objective-Rho/Rho-kinase (ROCK) pathway in vascular smooth muscle cells (VSMCs) plays an important role in the pathogenesis of cardiovascular diseases, including pulmonary arterial hypertension (PAH). Rho-kinase has 2 isoforms, ROCK1 and ROCK2, with different functions in different cells; ROCK1 for circulating inflammatory cells and ROCK2 for the vas...