To read all the articles in the series, you can go to the mini-site: "Aging of Your Heart and Blood Vessels is Risky" by clicking here.

Step 3: Use Medications and Dietary Supplements When Necessary and Under Supervision

While many people are on the "anti-drug" bandwagon, resorting to various natural products and touting their benefits, beware. There are some persons who need prescription medications for controlling hypertension and lowering lipid levels. For these persons the advantages of taking medications far outweigh not taking them. This is especially true for controlling high blood pressure when all other means, such as diet and exercise and stress reduction, have failed (Article # 13 "What's Your Blood Pressure and How Do Blood Pressure Medications work?" ).
It is also a fact that lipid lowering medications may be optimal therapy when a person already has coronary artery diseases and other lipid lowering methods have failed.

Several studies have shown that interventions which include statins, ACE inhibitors, and more recently angiotensin receptor blockers (ARBs) lessen coronary endothelial damage in patients with coronary artery disease.

Statins are drugs which lower LDL cholesterol by inhibiting an enzyme known as HMG-CoA reductase that is needed to produce cholesterol. When this enzyme is blocked the liver cannot make cholesterol. Some cholesterol is needed by the liver cells to function properly so they make receptors that collect the LDL cholesterol from the blood. This leaves less 'bad' cholesterol in the blood. The statins also increase nitric oxide production, reduce inflammation in the blood vessels, and stabilize plaque in the blood vessels which improves endothelial function.

ACE (angiotensin-converting enzyme) inhibitors prevent the production of angiotensin II (AII), a hormone produced by the kidneys and blood vessels. AII causes blood vessels to contract. You have learned that this reduces blood flow and increases blood pressure. ACE inhibitors work by blocking the enzyme that makes AII and breaks down the body's vasodilator, bradykinin. It's been shown that they also increase the release of nitric oxide from blood vessels and reduce the production of free radicals in the blood vessels.

Angiotensin receptor blockers (ARBs) lower blood pressure by a mechanism similar to, but more direct, than ACE inhibitors. They also help improve endothelial function.

These options, along with the medical indications and possible side effects, should be discussed with your physician to determine the risk-benefit ratio of adding a medication to a program to increase endothelial health.

The use of vitamins and supplements opens a can of worms with regard to treatment for endothelial dysfunction. Caution is indicated when self prescribing any vitamin or supplement, for they are not without possible harmful side effects.

Keeping this in mind, there is rational for the use of an L-arginine supplement in patients unable to produce it due to existing endothelial damage. These patients benefit from supplemental therapy because L-arginine, as you have learned, is necessary for the production of nitric oxide. Also acting as a blood thinner and anticoagulant, L-arginine may improve blood flow to and from the heart, and may reduce excess cholesterol. It may also preserve the elasticity of blood vessels through antioxidant actions. If it's so good, should we all be taking it? Not necessarily, for there's conflicting information regarding L-arginine's effect on tumor cells. It appears that some tumor cells are affected by L-arginine in an unwelcome fashion. Certain tumor cells, in particular breast cancer cells, thrive on the human growth hormone that L-arginine can trigger. This supplement is also not recommended for persons with serious infections or an inflammatory disease such as lupus or rheumatoid arthritis. In addition, people with any kind of herpes infection or a history of herpes should not take it, because the herpes virus flourishes on L-arginine. Used conservatively, for the right patients, its benefits may far outweigh its risks. Your physician should determine if the risk-benefit ratio warrants treatment in individual cases.

Several other "big players" that have a positive effect on endothelial function are vitamins C, E, and B-complex vitamins, omega-3 fatty acids, and polyphenols. Vitamins are essential micronutrients, required in small amount. They are either fat soluble (A,D,E,K) or water soluble (B and C). The B vitamins are thiamine, riboflavin, pyridoxine, pantothenic acid, niacin, biotin, folic acid and vitamin B12.

Vitamin C is an antioxidant, which means it helps remove cell-damaging oxygen compounds from the body. There are data which show improved endothelial function following anti-oxidant therapy with vitamin C.

The data on vitamin E related to endothelial function is more equivocal, though promising. In some cases just two weeks of vitamin E therapy appears to enhance vasodilatation. Vitamin E may be coming to the forefront as an indispensable member of the body's antioxidant system. It appears that is has a major role in the prevention of disease related to oxidative stress. Vitamin E also plays a role in brain function, relief of arthritis pain, prostate health, and strengthening the immune system. Natural topical use of vitamin E can reduce risk for ultraviolet induced skin damage. One needs to be careful in choosing a vitamin E supplement as all the bottles on the shelf are not necessarily the same. There is a natural source, called d-alpha, which is made from a natural food source such as soy; and a synthetic form, called dl-alpha, made from non-food sources. Natural-source vitamin E is retained longer by the body than synthetic forms and is much better for your body.

The B-complex vitamins (B6, B12, and folate) help to reduce homocysteine levels. As previously discussed, a high homocysteine level is a risk factor for heart disease. Homocysteine is derived from methionine, an aminoacid found in animal protein.

Like supplements, caution must be exercised in taking supplemental vitamins. When taken in daily doses that are more than 10 times the recommended daily allowance, fat soluble vitamins A and D are toxic, but vitamins E and K are not. Niacin, vitamin B6 and vitamin C are toxic when taken in high doses, but the other water-soluble vitamins are not. A lot of people mistakenly believe that because vitamin C is water soluble it is safe in any amount and the more you take the better. In fact, doses above 1,000 milligrams a day cause diarrhea, kidney stones in susceptible people, changes in the menstrual cycle and often rebound scurvy in people who suddenly stop taking such high does. High doses of vitamin E, although non-toxic, can increase the vitamin K requirement, which may cause bleeding in people taking anticoagulant drugs; it must therefore be used with caution since older persons are often taking blood thinners.

Omega-3 fatty acids (DHA and DPA) or fish oil supplementation has become increasing popular. These can improve endothelial health, in part, because they help the body make prostacyclin (PGI2) which, like nitric oxide, relaxes blood vessels, thereby increasing blood flow. Again, there is the qualification that caution is necessary. Omega-3s slightly reduce blood clot formation, so that persons taking aspirin or blood thinners or those who have bleeding tendencies need to check with their doctor before starting them; such people must be aware of warning signs such as bleeding gums or easy bruising, in order to stop taking omega-3s before more serious problems develop.

Polyphenols are the "new guys on the block" when it comes to supplementation. Phenols are found in the seeds of all grape varieties. The key active components are called procyanidins, a class of phenols that are potent antioxidants. It is thought that the phenols' powerful antioxidant properties help protect against LDL (low density lipoprotein) oxidation, keeping arterial linings healthy. Phenols also appear to improve circulation, and decrease fragility of the veins and capillary walls. While some of us may prefer to get this supplement in a glass of red wine or grape juice, procyanidins can also be found in grape seed extract as a nutritional supplement. Once again, consider whether or not taking your phenols from the bottle in the wine cabinet or the bottle in the medicine cabinet. A glass of pinot noir may cause a headache, while grape seed extract may cause excessive bleeding in those taking blood thinners; it can also interfere with cholesterol lowering drugs and cause dizziness or nausea. If you are allergic to grapes don't take from either bottle.

Considering the potential side effects of vitamins and supplements over natural products it's advisable to be extremely conservative about self prescribing or mega dosing on supplements or vitamins. Before risking your health and wasting your money ask the following questions: What kind of research has been done on the product? Are the claims regarding the product believable? Is the manufacturer reputable?

It's important to buy herbals, vitamins and supplements only from companies that provide a safe product. Do you know which ones meet these criteria? Does the label give information about standardized formulations? If not, you can't be sure how much of the active ingredient you are taking or that the same amount of the active ingredient is the same in each tablet. Does the label have information on the possible side effects; is it safe for people with chronic conditions? Does the label give you clear dosage instructions? Will the product interfere with any prescribed medications you are taking? Seek help from your pharmacist and physician before taking these products. With appropriate selection and appropriate information on adverse effects they can be valuable additional therapy towards a healthy endothelium for the right persons.

Step 4: Exercise to Keep Blood Vessels Young and Healthy

To understand the effect of exercise on vascular health we should first look at how aging affects the endothelium. Very simply, with aging the endothelium gradually loses the ability to regulate nitric oxide production. An inadequate amount of nitric oxide leads to changes in the endothelium that make older people prone to atherosclerosis, thrombosis and increased risk of heart attack. With aging there is also an increase in the number of free radicals in the blood stream which adversely affects endothelial function. The shear force of blood being forced through the blood vessels during exercise causes the endothelia cells to react favorably. The effects of regular exercise appear to include maintaining the production of nitric oxide and slowing down the aging process in the blood vessels. It is also believed that exercise protects the body by blocking free radicals.

In the past decade scientific evidence has shown that people who exercise not only live longer, they live better. It's proven that exercise helps prevent many of the changes associated with aging, diabetes, hypertension, osteoporosis and clogged arteries, as well as certain types of cancer. Numerous studies have shown that exercise training in coronary artery disease patients improves survival.

Many recent studies reinforce earlier ones in suggesting that the mechanism by which exercise reduces the progression of atherosclerosis and the risk for a repeat heart attack or stroke is improvement in blood vessel elasticity and endothelial function. Healthy human blood vessels widen in order to accommodate increases in blood flow. The key in this process is the endothelium which produces nitric oxide.

Long term exercise protects this inner lining of blood vessels from age-related changes and makes them more like those of a young person. When persons of differing exercise habits were studied - an older, sedentary group (over 60 year-olds), a younger sedentary group (less than 30) and older and younger athletic groups - it was found that the blood vessels of the older athletic group functioned just as well as either younger group. Evidence of the effects of the aging process was confined largely to the older, sedentary subjects. Exercise conditioning maintained the production of nitric oxide in the older exercising subjects and slowed down the aging process in their blood vessels. Other studies have shown that even moderate exercise has benefits. Moderate regular exercise reduces body fat, increases lean muscle mass, decreases blood pressure, decreases insulin resistance, and increases HDL cholesterol, all of which have a positive effect on endothelial cells.

Because exercise has been shown to be significant in maintaining blood vessel health the next article in this series will discuss moderate exercise and the older person.

Dr. Ed is a physician/scientist, who is internationally recognized for studies that range from humans to molecules on how the heart and blood vessels work in health and disease as the body ages.