Nitric Oxide Synthase: Heart health, blood pressure, and aging

Athletes are drinking beet juice to boost it, and people having chest pains pop nitroglycerine under their tongue with chest pain.  What are we talking about here? Nitric oxide – a little molecule needed in just the right amount.

Why is this important? Nitric oxide acts as a signaling molecule in the endothelium, impacting blood pressure, cardiovascular disease, brain health, and more. Lifestyle factors and genetic variants in nitric oxide related genes are important here. Everyone needs a healthy heart!

The Endothelium and Nitric Oxide Synthase:

We are going to dig into the creation of nitric oxide, what it does in the body, and why it is so important for heart health and healthy aging.

Nitric oxide (NO) acts as a signaling molecule in the body. It is also a free radical, so the body tightly regulates it. The body creates nitric oxide in specific reactions, but it only hangs around for less than 5 seconds.[ref]

Quick aside: Nitric oxide is not the same thing as nitrous oxide (laughing gas).

What does nitric oxide do in the body?

Nitric oxide’s composition consists of a nitrogen atom bound to an oxygen atom. This pairing leaves one electron free, thus making it a free radical. (Nitric oxide in the environment reacts to form acid rain, participates in ozone layer depletion, and can kill you if you breathe it at high concentrations. Same molecule, different roles when created inside the body.)

In biological systems, this tiny gaseous NO molecule acts as a signaling molecule in pretty much every living organism (bacteria, plants, fungi, animals). Because it is a tiny molecule, it can diffuse across cell membranes and move without needing to be transported.

One important role that nitric oxide plays in the body is to act as a signaling molecule from the endothelium to the surrounding layers of the blood vessels, causing the blood vessel to relax. This relaxation (vasodilation) increases blood flow. Vasodilation usually causes a decrease in blood pressure.

Producing nitric oxide in the endothelium

The enzyme responsible for producing nitric oxide in the endothelium is known as eNOS (endothelium nitric oxide synthase), and it is coded for by the NOS3 gene. Acetylcholine signals for the creation of eNOS, and then the nitric oxide synthase causes the creation of nitric oxide from arginine.

The NO produced in the endothelium regulates the constriction of the blood vessels, the stickiness of platelets, and leukocyte adhesion. It can diffuse from the endothelial cells into the neighboring smooth muscle cells, causing the muscle to relax.

Let’s pause for a moment here and explain the endothelium, and then get into the chemistry of creating NO.

Background: What is the endothelium?

The single layer of endothelial cells forming the lining of blood vessels and lymph vessels is called the endothelium. This thin cell layer is essential to the health of your blood vessels.  Endothelial cells can divide, and if there is a tear in a blood vessel, neighboring endothelial cells can proliferate and repair the tear. The endothelium also assists with controlling the rate of blood flow.[ref]

The endothelium acts as a barrier between everything in the bloodstream and the rest of the tissues of the body. Endothelial cells are selectively permeable – allowing in certain chemical and white blood cells and giving off signaling molecules.

Chemistry time: Creation of nitric oxide

Arginine, an amino acid, converts into nitric oxide with the addition of oxygen. The product of the reaction is l-citrulline and NO.

Two essential proteins needed in the reaction are tetrahydrobiopterin (BH4) and nitric oxide synthase (NOS3, eNOS). Nitric oxide synthase (eNOS) is the enzyme that catalyzes the reaction.

Nitric oxide synthase turns up in other areas of the body, so in the endothelium, nitric oxide (NO) synthase is referred to as eNOS to differentiate it.


eNOS (NOS3) consists of two identical proteins joined together with BH4, a cofactor essential to this process.  Without BH4 creating the bond, the reaction using just one nitric oxide synthase molecule will actually create a superoxide anion, which is a deleterious free radical.[ref][ref]

When NOS joins together (with BH4 to help) it is called ‘coupled’. When not joined together, it is called uncoupled eNOS.

Excess oxidative stress is a driver of cardiovascular disease. One problem with oxidative stress is it diminishes the levels of BH4. Without BH4 coupling the NOS3 molecules together, the reaction to form nitric oxide from l-arginine cannot happen. Instead, this results in the production of superoxide, a source of oxidative stress in the cell. Thus, excess oxidative stress decreases NOS3, driving the production of more oxidative stress.[ref]

What causes nitric oxide to be released?

The endothelium controls nitric oxide formation in multiple ways.

  • The blood flowing through your veins causes a shear force on the endothelium, and this mechanical force acts to regulate NO release. This is what goes on all day long, every day. Plus, this regulation of blood flow also keeps platelets from being activated and sticking together.[ref]
  • You can have a decrease in eNOS due to a lack of oxygen (hypoxia) or due to not enough BH4. A lack of eNOS causes blood pressure to rise. Alternatively, too much eNOS is also detrimental, so balance is needed.[ref]
  • Hyperglycemia, or high blood sugar, can also inhibit eNOS. This may play a big role in the cardiovascular problems found in people with diabetes.[ref]
  • Histamine (H1) receptors on the endothelial cell cause nitric oxide to be released in response to histamine. This is how histamine increases vascular permeability.[ref][ref]

Nitric oxide, endothelial function, and aging:

Cardiovascular disease (CVD) is the #1 cause of death in most countries, and about 70% of people over age 60 meet the criteria for CVD.

Researchers discovered decades ago that nitric oxide production in the endothelial cells lining the arteries is key to the health of the cardiovascular system.

As we age, there is an increase in oxidative stress in the body and a decrease in nitric oxide bioavailability. This reduction in nitric oxide directly drives the stiffening of the arteries seen in CVD.[ref]

Cardiovascular disease can arguably be considered a problem of imbalanced reactive oxygen species – e.g. oxidative stress. A simplified explanation is that this increase in oxidative stress decreases eNOS, thus increasing blood pressure.[ref]

What causes the increase in ROS over what the cell needs as we age? Things like chronic infection, mold toxins, and heavy metals.

Exercise, heart health, and NOS3

Good blood flow and transport of oxygen are essential for athletic performance, and nitric oxide is one variable athletes target in order to increase their endothelial function.

Exercise causes increased blood flow and increased shear stress in the blood vessels. This increase causes eNOS to be released and it is why exercise helps to lower blood pressure for some people.[ref]

NOS3 Genetic variants related to NO production:

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NOS3 gene: codes for nitric oxide synthase

Quite a few studies on the NOS3 gene variants point to interactions with cardiovascular disease risk and blood pressure. For many studies, though the increase in risk is statistically significant, but not large. I encourage you to read through the research studies referenced.

Genetics may increase your susceptibility to coronary artery disease, but CAD is going to end up being due to a combination of lifestyle / environmental factors along with the genes.

One more caveat: there may be gender or population group differences as well with the NOS3 variants. One large prospective study found that the NOS3 variants did not impact hypertension risk for Caucasian women.[ref]


Check your genetic data for rs891512 G24943A or IVS25+15 (23andMe v5; AncestryDNA):

  • G/G: typical (more common allele)
  • A/G: higher blood pressure, increased risk of coronary artery disease
  • A/A: higher blood pressure[ref][ref], increased risk of coronary artery disease[ref]

Members: Your genotype for rs891512 is .


Check your genetic data for rs1800779 (23andMe v4, v5; AncestryDNA):

  • A/A: typical
  • A/G: decreased NOS3 expression (compared to AA); increased risk of high blood pressure and cardiovascular disease
  • G/G: decreased NOS3 expression (compared to AA); increased risk of high blood pressure and cardiovascular disease[ref] increased risk of primary open-angle glaucoma (women)[ref]

Members: Your genotype for rs1800779 is .


Check your genetic data for rs4496877 (23andMe v4; AncestryDNA):

  • G/G: typical
  • G/T: increased risk of hypertension in older males (Chinese population)[ref] increased bilirubin in people who are older or who drink[ref]
  • T/T: increased risk of hypertension in older males (Chinese population); increased bilirubin in people who are older or who drink[ref]

Members: Your genotype for rs4496877 is .


Check your genetic data for rs2070744 (23andMe v5):

  • C/C: increased risk of coronary artery disease (Asian, Caucasian)[ref] increased risk of osteoporosis[ref] decreased risk of hemorrhagic stroke, atrial fibrillation[ref][ref]
  • C/T: increased risk of hypertension
  • T/T: typical

Members: Your genotype for rs2070744 is .



Nitric oxide is needed in just the right levels, specific to the tissue in question.

Increasing endothelial nitric oxide synthase may help with hypertension for some people. This may especially be true in conjunction with the above NOS3 genetic variants.[ref]

If you are under a doctor’s care, please check with your doctor before making any changes.

Increasing BH4 availability:

BH4 (tetrahydrobiopterin) is an essential cofactor for nitric oxide production. Your body naturally produces BH4, and under normal conditions, it gets recycled and reused in the cell.  But when oxidative stress is high (excess reactive oxygen species), it can be used up more quickly.[ref]

Studies show that Vitamin C increases nitric oxide through increasing BH4 bioavailability.[ref]

Similarly, curcumin supplementation has been shown to increase NO by reducing oxidative stress.[ref] A clinical trial of 2,000 mg/day of curcumin had beneficial effects on increasing nitric oxide in relation to endothelial function tests for cardiovascular disease.[ref]

Folate and methyl folate:

As an antioxidant, folate (vitamin B9) or methylfolate (an active version of folate) can improve endothelial function (a little) through decreasing oxidative stress.[ref][ref][ref]

For people with the MTHFR C677T variant, riboflavin (vitamin B2) may also help. Check your MTHFR gene here. 

DHFR, an important enzyme in the folate cycle, also acts to regenerate BH4 when it has been lost due to high oxidative stress.[ref] You can check your genetic variants for DHFR and read more about this enzyme.

Foods high in folate include dark leafy green veggies, legumes, and beef liver.


L-arginine is an amino acid that is available as a supplement. It is the foundation of nitric oxide production in the body. Some studies show that supplemental l-arginine can increase endothelium-dependent vasodilation.[ref] Note that all studies on l-arginine do not show positive results. The article does a great job of explaining the studies on this supplement.

Beet juice:

A popular way for athletes to try to boost nitric oxide is to drink beet juice.  Trials on this show mixed results. For example, one clinical trial showed that nitric oxide synthase increased, but it had no effect on athletic performance.[ref]

Related Genes and Topics:

Interaction between high-fat diet, blood pressure, and your genes
Research shows that people with the ACE deletion genotype are likely to have an increase in blood pressure on a high-fat diet. Find out how a high-fat diet interacts with your genes.

High blood pressure due to AGTR1 gene variants
There are several causes of high blood pressure. Genetic variants in the AGTR1 gene are strongly linked with blood pressure — and there are specific lifestyle changes that should work to change your blood pressure if you carry the variants.

Author Information:   Debbie Moon
Debbie Moon is the founder of Genetic Lifehacks. She holds a Master of Science in Biological Sciences from Clemson University and an undergraduate degree in engineering from Colorado School of Mines. Debbie is a science communicator who is passionate about explaining evidence-based health information. Her goal with Genetic Lifehacks is to bridge the gap between the research hidden in scientific journals and everyone's ability to use that information. To contact Debbie, visit the contact page.