Effects of Oral Antioxidant Cocktail in Cardiovascular Disease Patients
Effects of Oral Antioxidant Cocktail in Cardiovascular Disease Patients
Title: Effects of oral antioxidant cocktail on vascular function and muscle function in
 cardiovascular disease patients

 Cardiovascular disease (CVD) generally refers to various conditions involving narrowed or
 blocked dysfunctional blood vessels that often lead to heart attack or stroke. One of the
 main contributors to blood vessel dysfunction is damage to the vascular endothelium. This
 often results from the accumulation of oxidative stress (OS) and inflammation due to a
 decrease in blood flow and oxygen transport to the body's organs and skeletal muscle.

 The body's natural antioxidant defense system cannot keep up with the high level of OS
 clearance necessary to maintain proper vascular homeostasis. Previous research has addressed
 the use of single antioxidants (e.g. vitamin E, beta-carotene, ascorbic acid) in CVD
 patients, but the use of a combination of antioxidants has yet to be examined. Therefore, the
 purpose of this study is to examine the effects of acute oral antioxidant cocktail
 administration (containing vitamin C, E, and alpha-lipoic acid) on oxidative stress, vascular
 function, autonomic function (heart rate variability), leg blood flow, leg muscle tissue
 oxygenation, and walking capacity in CVD patients.

 This is a parallel study design that will assess the effects of oral antioxidant cocktail
 administration on CVD patients ages 50-85. Subjects will be required to visit the lab 1 time.
 This visit will consist of 1) obtaining informed consent and questions, 2) baseline blood
 sampling and baseline measurements of endothelial function, arterial stiffness, autonomic
 function (heart rate variability), leg blood flow, leg muscle oxygenation, and a walking
 test, 3) first dose oral antioxidant cocktail administration followed by a 2-hour break, 4)
 second dose oral antioxidant cocktail 30 minutes after the first dose, 5) post-consumption
 blood sampling and measurements of endothelial function, arterial stiffness, autonomic
 function (heart rate variability), leg blood flow, leg muscle oxygenation, and a walking
 test.
Cardiovascular disease (CVD) is one of the leading causes of death in the United States. CVD
 is attributed to a combination of major risk factors including hypertension, dyslipidemia,
 obesity, poor diet, low physical activity levels, and vascular endothelial cell dysfunction.

 The vascular endothelial cells (VECs) have significant control over vascular homeostatic
 regulation. In the case of mechanical and chemical stimuli, VECs can release vasoactive
 substances to regulate vascular tone, cell adhesion, and vascular smooth muscle cell (VSMC)
 proliferation. When the endothelium is damaged and becomes dysfunctional, atherosclerotic
 changes take place that can contribute to the development of CVD and atherosclerosis.

 Endothelial dysfunction has been partially attributed to high levels of reactive oxygen
 species (ROS) causing significant oxidative stress (OS). OS is defined as an imbalance
 between the rate of ROS production and the rate of ROS clearance by the antioxidant defense
 system, with insufficient clearance leading to oxidative damage of the vasculature. High
 levels of OS have been shown to negatively affect the vascular endothelium by increasing VSMC
 proliferation and inflammation, which may result in vascular remodeling. Increased OS also
 attenuates the bioavailability of nitric oxide, a potent vasodilator, and can further
 exacerbate the structural and functional changes of the vascular endothelium that are
 associated with the development of CVD.

 When the vascular endothelium becomes dysfunctional (partially due to OS), blood flow and
 vascular tone regulation become impaired, which then negatively affects O2 transport. Without
 proper blood flow and O2 transport, exercise capacity becomes attenuated. This is a major
 concern for CVD patients, because exercise is an effective non-pharmacological therapeutic
 treatment for many of the CVD risk factors including obesity, dyslipidemia, hypertension, and
 metabolic syndrome. Therefore, improvement of the antioxidant defense system could alleviate
 high OS, and improve vasodilatory capacity of blood vessels, blood flow and O2 transport, and
 by extension, can increase exercise capacity. This would make exercise a more viable
 treatment option for CVD patients.

 The antioxidant defense system contains numerous enzymatic and non-enzymatic antioxidants,
 including catalase, superoxide dismutase, glutathione peroxidase, vitamins A, E, and C, along
 with glutathione, ubiquinone, and flavanoids. The antioxidant defense system has been found
 to be attenuated in CVD patients, particularly in those with peripheral arterial disease.
 However, as ROS production increases, this antioxidant defense system can be overwhelmed,
 leading to OS and damage to the tissues. Antioxidant capacity may be improved through
 supplementation in order to provide better OS clearance in the body, which could then result
 in better blood flow and O2 delivery to the muscles and other organs in the body.

 Previous research has shown that blood flow increases after antioxidant intake. Leg blood
 flow increased significantly in chronic obstructive pulmonary disease (COPD) patients during
 knee extension exercise in watts (W) in comparison to healthy age-matched controls (3W:
 1,798±128 vs. 1,604±100 mL/min, 6W: 1,992±120 vs. 1,832±109 mL/min, 9W: 2,187±136 vs.
 2,035±114 mL/min, P < 0.05, antioxidant supplement vs. control, respectively) following acute
 antioxidant supplementation (~2 hours prior). In patients with open-angle glaucoma,
 antioxidant supplementation for one month significantly increased biomarkers of ocular blood
 flow within the retina and retrobulbar vascular beds, where peak systolic velocity increased
 by 7.3% (P=0.013) and end diastolic velocity increased by 11% (P=0.014). Cerebral blood flow
 has also been shown to increase following 12 weeks of antioxidant supplementation. Overall,
 the use of antioxidant intake, acute and chronic, has shown to improve blood flow to various
 areas within the vasculature.

 Previous research also indicates that the increase in blood flow is indicative of greater O2
 supply to the measured area. During knee extension exercise in COPD patients, leg O2
 consumption increased significantly in comparison to age-matched controls following acute
 antioxidant intake (3W: 210±15 vs. 173 ± 12 mL O2/min, 6W: 237±15 vs. 217±14 mL O2/min, 9W:
 260±18 mL vs. 244±16 mL O2/min, P< 0.05, antioxidant supplement vs. control, respectively).
 Following 12 weeks of antioxidant use, oxygen utilization in the right prefrontal cortex
 increased and was strongly associated with the increase in cerebral blood flow (SO2, from
 68.21±1.65% to 66.58±1.58%, P=0.001, pre vs. post, respectively).

 Pharmacological interventions are often aimed toward controlling cholesterol and blood
 pressure; however, OS reduction and vascular endothelial function are not common therapeutic
 targets. Previous research has addressed the use of antioxidants in CVD patients, but it has
 focused on the intake of a single antioxidant (e.g. vitamin E, beta-carotene, ascorbic acid)
 and not a combination of antioxidants. The utilization of a combination of antioxidants and
 their effects on blood flow and oxygen transport in CVD are as of yet unclear. The purpose of
 this proposed study is to examine the effects of acute administration of an oral antioxidant
 cocktail (containing vitamin C, E, and a-lipoic acid E) on oxidative stress, vascular
 endothelial function, autonomic function, blood flow, and oxygen delivery during a walking
 test. It is hypothesized that oral antioxidant cocktail administration will reduce oxidative
 stress markers, and will increase both vascular endothelial function and blood flow, thus
 increasing oxygen delivery to the muscles and improving walking capacity. This pending data
 from acute antioxidant administration will give insight to long-term antioxidant use in CVD
 patients and its effects on oxidative stress, blood flow, and the integration of O2 transport
 and utilization in the body.
Cardiovascular Disease Inclusion Criteria:

 1. be able to give written, informed consent

 2. be diagnosed with CVD

 3. be between 50-85 years old

 4. be postmenopausal, meaning having had cessation of menses for at least 12 consecutive
 months

 Healthy Control Inclusion Criteria:

 1. be able to give written, informed consent

 2. no CVD conditions

 3. be between 50-85 years old

 4. be postmenopausal, meaning having had cessation of menses for at least 12 consecutive
 months

 Exclusion Criteria (Both Groups):

 1. chronic kidney/renal disease

 2. chronic heart failure

 3. neuromuscular disease

 4. known cancer

 5. already supplementing with antioxidants or vitamins within 5 days of the study

 6. pregnant or nursing women