NO transfer reactions between protein and peptide cysteines have been proposed to represent regulated signaling processes. We used the pharmaceutical antioxidant N-acetylcysteine (NAC) as a bait reactant to measure NO transfer reactions in blood and to study the vascular effects of these reactions in vivo. NAC was converted to S-nitroso-N-acetylcysteine (SNOAC), decreasing erythrocytic S-nitrosothiol content, both during wholeblood deoxygenation ex vivo and during a 3-week protocol in which mice received high-dose NAC in vivo. Strikingly, the NAC-treated mice developed pulmonary arterial hypertension (PAH) that mimicked the effects of chronic hypoxia. Moreover, systemic SNOAC administration recapitulated effects of both NAC and hypoxia. eNOS-deficient mice were protected from the effects of NAC but not SNOAC, suggesting that conversion of NAC to SNOAC was necessary for the development of PAH. These data reveal an unanticipated adverse effect of chronic NAC administration and introduce a new animal model of PAH. Moreover, evidence that conversion of NAC to SNOAC during blood deoxygenation is necessary for the development of PAH in this model challenges conventional views of oxygen sensing and of NO signaling.Introduction NO transfer reactions between protein and peptide cysteines have been proposed to represent regulated signaling processes (1, 2). For example, NO transfer from deoxygenated erythrocytes to glutathione ex vivo forms S-nitrosoglutathione (GSNO) (3). GSNO can signal acute vascular and central ventilatory effects characteristic of oxyhemoglobin desaturation (3-4) that are regulated by γ-glutamyl transpeptidase (GGT), GSNO reductase (GSNOR), and other enzymes (1, 3-6). However, direct measurement of S-nitrosothiol signaling in vivo has proven challenging because of the metabolism and tissue-specific localization of endogenous S-nitrosothiol species (1, 3, 4, 6). We have addressed these challenges by using N-acetylcysteine (NAC) as a bait reactant, allowing the stable NO transfer product, S-nitroso-N-acetylcysteine (SNOAC), to be distinguished by mass spectrometry (MS) from endogenous S-nitrosothiols. We report that NAC is converted to SNOAC in mice in vivo. Furthermore, chronic, systemic administration of either NAC or SNOAC to mice causes hypoxia-mimetic pulmonary arterial hypertension (PAH). These data reveal a previously unappreciated vascular toxicity of NAC and of S-nitrosothiols. Moreover, they suggest that S-nitrosothiol transfer reactions can signal hypoxia in vivo.PAH is characterized by increased pressure in the pulmonary arteries (PAs), increased RV weight, and thickening and remodeling of small PAs. Untreated human PAH can progress to right