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COX Products Reduce Endothelium-Dependent Relaxations 245(endothelium-derived relaxing factor). 10 In addition, Virdis et al 1 report that substantial relaxations to acetylcholine remain in the presence of L-NAME (NÏ-nitro-L-arginine methyl ester) (with or without COX inhibitors), although they do not comment further on the mechanism underlying them. In the absence of sympathetic nerve activity under their in vitro experimental conditions (which they amusingly term clinical setting), these L-NAME-resistant relaxations to acetylcholine can reasonably be attributed to endothelium-dependent hyperpolarization. They are remarkably similar in preparations of normotensive and essential hypertensive subjects.1 Hence, is the endothelium of the latter truly dysfunctional or is it trying very hard to cope with the abnormal events in the media?At first sight, the situation in the hypertensive humans, with medial COX-2-generating superoxide anions that scavenge endothelium-derived NO, seems to differ fundamentally from that in the SHR, the most commonly used animal model of essential hypertension. Indeed, in the latter endothelial COX-1 can be upregulated and seems to play a dominant role in endothelium-dependent responses by generating vasoconstrictor prostaglandins but also ROS. 4,5,8 However, does it really matter whether COX-1 or COX-2 are upregulated and whether the upregulation is in the endothelium or the media? Indeed, the consequences seem to be the same, and the common result is abnormal endothelium-dependent relaxation to acetylcholine, an accepted biomarker of increased risk for vascular disease (Figure). Is the important question not why do we see upregulation of COX (whether COX-1 or COX-2) in the vascular wall (whether intima or media) of chronically hypertensive mammals? What feedback loop is dysregulated to the extent that such excessive production of ROS and vasoconstrictor prostanoids is permitted? If one takes the simple-minded approach that production of prostaglandins is the primary role of COX, this implies that any regulatory feedback loop must involve the end products of the enzyme. Then, one can only speculate, in the absence of overt signs of local inflammation, that the COX overexpression after chronic exposure to high blood pressure results from an imbalance in prostanoid receptor responsiveness/sensitivity in either endothelial (SHR) or vascular smooth muscle (essential hypertensive human) cells preventing end product feedback inhibition.The unequivocal message given by the tissues studied by Virdis et al 1 is that, at least in small arteries of subcutaneous fat of hypertensive subjects, COX-2, a usual suspect in pathology, is indeed the major culprit in causing abnormal endothelium-dependent relaxations to acetylcholine. Their findings throw a new light on the vascular, possibly beneficial effects of COX-2 inhibition. Whether or not, after the rofecoxib tsunami, their enthusiasm will be sufficient to reactivate interest in the pharmaceutic...