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Circulation. 1998;98:1842-1847

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(Circulation. 1998;98:1842-1847.)
© 1998 American Heart Association, Inc.


Clinical Investigation and Reports

Asymmetric Dimethylarginine (ADMA): A Novel Risk Factor for Endothelial Dysfunction

Its Role in Hypercholesterolemia

Rainer H. Böger, MD; Stefanie M. Bode-Böger, MD; Andrzej Szuba, MD; Philip S. Tsao, PhD; Jason R. Chan, BS; Oranee Tangphao, MD; Terrence F. Blaschke, MD; ; John P. Cooke, MD, PhD

From the Divisions of Cardiovascular Medicine (R.H.B., S.M.B.-B., P.S.T., J.R.C., J.P.C.) and Clinical Pharmacology (O.T., T.F.B.), Stanford University School of Medicine, Stanford, Calif, and Department of Angiology (A.S.), Jaegellonian University, Wroclaw, Poland.

Correspondence to John P. Cooke, MD, PhD, Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Stanford, CA 94305-5246.

Background—Asymmetric dimethylarginine (ADMA) is an endogenous competitive inhibitor of nitric oxide (NO) synthase. Because endothelial NO elaboration is impaired in hypercholesterolemia, we investigated whether plasma concentrations of ADMA are elevated in young, clinically asymptomatic hypercholesterolemic adults. We further studied whether such elevation of ADMA levels was correlated with impaired endothelium-dependent, NO-mediated vasodilation and urinary nitrate excretion. In a randomized, double-blind, placebo-controlled study, we investigated whether these changes could be reversed with exogenous L-arginine.

Methods and Results—We measured plasma levels of L-arginine, ADMA, and symmetrical dimethylarginine (SDMA) by high-performance liquid chromatography in 49 hypercholesterolemic (HC) and 31 normocholesterolemic (NC) humans. In 8 HC subjects, endothelium-dependent forearm vasodilation was assessed before and after an intravenous infusion of L-arginine or placebo and compared with 8 NC control subjects. ADMA levels were significantly elevated by >100% (2.17±0.15 versus 1.03±0.09 µmol/L; P<0.05) in HC subjects compared with NC adults. L-Arginine levels were similar, resulting in a significantly decreased L-arginine/ADMA ratio in HC subjects (27.7±2.4 versus 55.7±5.4; P<0.05). In 8 HC subjects, intravenous infusion of L-arginine significantly increased the L-arginine/ADMA ratio and normalized endothelium-dependent vasodilation and urinary nitrate excretion. ADMA levels were inversely correlated with endothelium-mediated vasodilation (R=0.762, P<0.01) and urinary nitrate excretion rates (R=0.534, P<0.01).

Conclusions—We find that ADMA is elevated in young HC individuals. Elevation of ADMA is associated with impaired endothelium-dependent vasodilation and reduced urinary nitrate excretion. This abnormality is reversed by administration of L-arginine. ADMA may be a novel risk factor for endothelial dysfunction in humans.


Key Words: asymmetric dimethylarginine • atherosclerosis • nitric oxide • endothelium-derived factors • vasodilation




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S. P. Schulman, L. C. Becker, D. A. Kass, H. C. Champion, M. L. Terrin, S. Forman, K. V. Ernst, M. D. Kelemen, S. N. Townsend, A. Capriotti, et al.
L-Arginine Therapy in Acute Myocardial Infarction: The Vascular Interaction With Age in Myocardial Infarction (VINTAGE MI) Randomized Clinical Trial
JAMA, January 4, 2006; 295(1): 58 - 64.
[Abstract] [Full Text] [PDF]


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J. Nutr.Home page
M. Reimann, J. Dierkes, A. Carlsohn, D. Talbot, M. Ferrari, J. Hallund, W. L. Hall, K. Vafeiadou, U. Huebner, F. Branca, et al.
Consumption of Soy Isoflavones Does Not Affect Plasma Total Homocysteine or Asymmetric Dimethylarginine Concentrations in Healthy Postmenopausal Women
J. Nutr., January 1, 2006; 136(1): 100 - 105.
[Abstract] [Full Text] [PDF]


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Am. J. Physiol. Heart Circ. Physiol.Home page
K. A. Carello, S. E. Whitesall, M. C. Lloyd, S. S. Billecke, and L. G. D'Alecy
Asymmetrical dimethylarginine plasma clearance persists after acute total nephrectomy in rats
Am J Physiol Heart Circ Physiol, January 1, 2006; 290(1): H209 - H216.
[Abstract] [Full Text] [PDF]


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Arterioscler. Thromb. Vasc. Bio.Home page
C. T. Chan, P. J. Harvey, R. Boger, A. Pierratos, and J. S. Floras
Letter to the Editor: Dissociation Between the Short-Term Effects of Nocturnal Hemodialysis on Endothelium Dependent Vasodilation and Plasma ADMA
Arterioscler Thromb Vasc Biol, December 1, 2005; 25(12): 2685 - 2686.
[Full Text] [PDF]


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Arterioscler. Thromb. Vasc. Bio.Home page
X. Jiang, F. Yang, H. Tan, D. Liao, R. M. Bryan Jr, J. K. Randhawa, R. E. Rumbaut, W. Durante, A. I. Schafer, X. Yang, et al.
Hyperhomocystinemia Impairs Endothelial Function and eNOS Activity via PKC Activation
Arterioscler Thromb Vasc Biol, December 1, 2005; 25(12): 2515 - 2521.
[Abstract] [Full Text] [PDF]


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J Am Coll CardiolHome page
J. Ruano, J. Lopez-Miranda, F. Fuentes, J. A. Moreno, C. Bellido, P. Perez-Martinez, A. Lozano, P. Gomez, Y. Jimenez, and F. Perez Jimenez
Phenolic Content of Virgin Olive Oil Improves Ischemic Reactive Hyperemia in Hypercholesterolemic Patients
J. Am. Coll. Cardiol., November 15, 2005; 46(10): 1864 - 1868.
[Abstract] [Full Text] [PDF]


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Vasc MedHome page
R. K Oka, A. Szuba, J. C Giacomini, and J. P Cooke
A pilot study of l-arginine supplementation on functional capacity in peripheral arterial disease
Vascular Medicine, November 1, 2005; 10(4): 265 - 274.
[Abstract] [PDF]


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Clin. Chem.Home page
J. Martens-Lobenhoffer, S. Westphal, F. Awiszus, S. M. Bode-Boger, and C. Luley
Determination of Asymmetric Dimethylarginine: Liquid Chromatography-Mass Spectrometry or ELISA?
Clin. Chem., November 1, 2005; 51(11): 2188 - 2189.
[Full Text] [PDF]


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Proc. Natl. Acad. Sci. USAHome page
T. Hayashi, P. A. R. Juliet, H. Matsui-Hirai, A. Miyazaki, A. Fukatsu, J. Funami, A. Iguchi, and L. J. Ignarro
L-citrulline and L-arginine supplementation retards the progression of high-cholesterol-diet-induced atherosclerosis in rabbits
PNAS, September 20, 2005; 102(38): 13681 - 13686.
[Abstract] [Full Text] [PDF]


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CirculationHome page
M. Tanaka, K. Sydow, F. Gunawan, J. Jacobi, P. S. Tsao, R. C. Robbins, and J. P. Cooke
Dimethylarginine Dimethylaminohydrolase Overexpression Suppresses Graft Coronary Artery Disease
Circulation, September 13, 2005; 112(11): 1549 - 1556.
[Abstract] [Full Text] [PDF]


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Eur Heart JHome page
T. K. Krempl, R. Maas, K. Sydow, T. Meinertz, R. H. Boger, and J. Kahler
Elevation of asymmetric dimethylarginine in patients with unstable angina and recurrent cardiovascular events
Eur. Heart J., September 2, 2005; 26(18): 1846 - 1851.
[Abstract] [Full Text] [PDF]


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Ann Rheum DisHome page
I E M Bultink, T Teerlink, J A Heijst, B A C Dijkmans, and A E Voskuyl
Raised plasma levels of asymmetric dimethylarginine are associated with cardiovascular events, disease activity, and organ damage in patients with systemic lupus erythematosus
Ann Rheum Dis, September 1, 2005; 64(9): 1362 - 1365.
[Abstract] [Full Text] [PDF]


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CirculationHome page
P. Voisine, J. Li, C. Bianchi, T. A. Khan, M. Ruel, S.-H. Xu, J. Feng, A. Rosinberg, T. Malik, Y. Nakai, et al.
Effects of L-Arginine on Fibroblast Growth Factor 2-Induced Angiogenesis in a Model of Endothelial Dysfunction
Circulation, August 30, 2005; 112(9_suppl): I-202 - I-207.
[Abstract] [Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
P. Vallance and J. Leiper
Asymmetric Dimethylarginine and Kidney Disease--Marker or Mediator?
J. Am. Soc. Nephrol., August 1, 2005; 16(8): 2254 - 2256.
[Full Text] [PDF]


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Clin. Chem.Home page
E. Schwedhelm, J. Tan-Andresen, R. Maas, U. Riederer, F. Schulze, and R. H. Boger
Liquid Chromatography-Tandem Mass Spectrometry Method for the Analysis of Asymmetric Dimethylarginine in Human Plasma
Clin. Chem., July 1, 2005; 51(7): 1268 - 1271.
[Full Text] [PDF]


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Vasc MedHome page
S. Anthony, J. Leiper, and P. Vallance
Endogenous production of nitric oxide synthase inhibitors
Vascular Medicine, July 1, 2005; 10(1_suppl): S3 - S9.
[Abstract] [PDF]


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Vasc MedHome page
J. P Cooke
ADMA: its role in vascular disease
Vascular Medicine, July 1, 2005; 10(1_suppl): S11 - S17.
[Abstract] [PDF]


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Vasc MedHome page
R. H Boger
Asymmetric dimethylarginine (ADMA) and cardiovascular disease: insights from prospective clinical trials
Vascular Medicine, July 1, 2005; 10(1_suppl): S19 - S25.
[Abstract] [PDF]


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Vasc MedHome page
S. Dayal and S. R Lentz
ADMA and hyperhomocysteinemia
Vascular Medicine, July 1, 2005; 10(1_suppl): S27 - S33.
[Abstract] [PDF]


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Vasc MedHome page
R. Maas
Pharmacotherapies and their influence on asymmetric dimethylargine (ADMA)
Vascular Medicine, July 1, 2005; 10(1_suppl): S49 - S57.
[Abstract] [PDF]


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Vasc MedHome page
E. Schwedhelm
Quantification of ADMA: analytical approaches
Vascular Medicine, July 1, 2005; 10(1_suppl): S89 - S95.
[Abstract] [PDF]


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Vasc MedHome page
R. H Boger, E. Schwedhelm, R. Maas, S. Quispe-Bravo, and C. Skamira
ADMA and oxidative stress may relate to the progression of renal disease: rationale and design of the VIVALDI study
Vascular Medicine, July 1, 2005; 10(1_suppl): S97 - S102.
[Abstract] [PDF]


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Arterioscler. Thromb. Vasc. Bio.Home page
J. T. Kielstein, S. M. Bode-Boger, G. Hesse, J. Martens-Lobenhoffer, A. Takacs, D. Fliser, and M. M. Hoeper
Asymmetrical Dimethylarginine in Idiopathic Pulmonary Arterial Hypertension
Arterioscler Thromb Vasc Biol, July 1, 2005; 25(7): 1414 - 1418.
[Abstract] [Full Text] [PDF]


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J. Thorac. Cardiovasc. Surg.Home page
P. Voisine, C. Bianchi, T. A. Khan, M. Ruel, S.-H. Xu, J. Feng, J. Li, T. Malik, A. Rosinberg, and F. W. Sellke
Normalization of coronary microvascular reactivity and improvement in myocardial perfusion by surgical vascular endothelial growth factor therapy combined with oral supplementation of L-arginine in a porcine model of endothelial dysfunction
J. Thorac. Cardiovasc. Surg., June 1, 2005; 129(6): 1414 - 1420.
[Abstract] [Full Text] [PDF]


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Vasc MedHome page
S. Anthony, J. Leiper, and P. Vallance
Endogenous production of nitric oxide synthase inhibitors
Vascular Medicine, May 1, 2005; 10(2_suppl): S3 - S9.
[Abstract] [PDF]


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Vasc MedHome page
J. P Cooke
ADMA: its role in vascular disease
Vascular Medicine, May 1, 2005; 10(2_suppl): S11 - S17.
[Abstract] [PDF]


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Vasc MedHome page
R. H Boger
Asymmetric dimethylarginine (ADMA) and cardiovascular disease: insights from prospective clinical trials
Vascular Medicine, May 1, 2005; 10(2_suppl): S19 - S25.
[Abstract] [PDF]


Home page
Vasc MedHome page
S. Dayal and S. R Lentz
ADMA and hyperhomocysteinemia
Vascular Medicine, May 1, 2005; 10(2_suppl): S27 - S33.
[Abstract] [PDF]


Home page
Vasc MedHome page
R. Maas
Pharmacotherapies and their influence on asymmetric dimethylargine (ADMA)
Vascular Medicine, May 1, 2005; 10(2_suppl): S49 - S57.
[Abstract] [PDF]


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Vasc MedHome page
E. Schwedhelm
Quantification of ADMA: analytical approaches
Vascular Medicine, May 1, 2005; 10(2_suppl): S89 - S95.
[Abstract] [PDF]


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Vasc MedHome page
R. H Boger, E. Schwedhelm, R. Maas, S. Quispe-Bravo, and C. Skamira
ADMA and oxidative stress may relate to the progression of renal disease: rationale and design of the VIVALDI study
Vascular Medicine, May 1, 2005; 10(2_suppl): S97 - S102.
[Abstract] [PDF]


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Eur J Heart FailHome page
J. Niebauer, A. L. Clark, K. M. Webb-Peploe, R. Boger, and A. J.S. Coats
Home-based exercise training modulates pro-oxidant substrates in patients with chronic heart failure
Eur J Heart Fail, March 2, 2005; 7(2): 183 - 188.
[Abstract] [Full Text] [PDF]


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Vasc MedHome page
V Achan, H. Ho, C Heeschen, M Stuehlinger, J. Jang, M Kimoto, P Vallance, and J. Cooke
ADMA regulates angiogenesis: genetic and metabolic evidence
Vascular Medicine, February 1, 2005; 10(1): 7 - 14.
[Abstract] [PDF]


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J. Clin. Endocrinol. Metab.Home page
K. Krzyzanowska, F. Mittermayer, H.-P. Kopp, M. Wolzt, and G. Schernthaner
Weight Loss Reduces Circulating Asymmetrical Dimethylarginine Concentrations in Morbidly Obese Women
J. Clin. Endocrinol. Metab., December 1, 2004; 89(12): 6277 - 6281.
[Abstract] [Full Text] [PDF]


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JPEN J Parenter Enteral NutrHome page
R. J. Nijveldt, T. Teerlink, M. P. C. Siroen, B. van der Hoven, H. A. Prins, M. J. Wiezer, C. Meijer, J. R. M. van der Sijp, M. A. Cuesta, S. Meijer, et al.
Elevation of Asymmetric Dimethylarginine (ADMA) in Patients Developing Hepatic Failure After Major Hepatectomy
JPEN J Parenter Enteral Nutr, November 1, 2004; 28(6): 382 - 387.
[Abstract] [Full Text] [PDF]


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Arterioscler. Thromb. Vasc. Bio.Home page
F. Scalera, J. Borlak, B. Beckmann, J. Martens-Lobenhoffer, T. Thum, M. Tager, and S. M. Bode-Boger
Endogenous Nitric Oxide Synthesis Inhibitor Asymmetric Dimethyl L-Arginine Accelerates Endothelial Cell Senescence
Arterioscler Thromb Vasc Biol, October 1, 2004; 24(10): 1816 - 1822.
[Abstract] [Full Text] [PDF]


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J. Nutr.Home page
N. Gokce
L-Arginine and Hypertension
J. Nutr., October 1, 2004; 134(10): 2807S - 2811S.
[Abstract] [Full Text] [PDF]