Effect of acute nitrate and citrulline supplementation on muscle microvascular response to ischemia-reperfusion in healthy humans

The effect of microencapsulated watermelon rind (Citrullus lanatus) and beetroot (Beta vulgaris L.) ingestion on ischemia/reperfusion-induced endothelial dysfunction: a randomised clinical trial

Endothelial dysfunction is commonly associated with a cardiovascular event, such as myocardial infarction. Myocardial infarction is marked by an ischemia/reperfusion (IR) phenomenon associated with endothelial dysfunction, contributing even more to future cardiovascular events. Although the supplementation with L-citrulline and nitrate from watermelon and beetroot have been used to improve vascular function, the effect of microencapsulated watermelon rind (WR) or its co-ingestion with beetroot (WR + B) on endothelial IR injury has not been addressed. Therefore, this study aimed to investigate the effect of a single dose of WR and WR + B on IR-induced macro-and microvascular dysfunction. In a randomized, crossover, placebo-controlled study, 12 volunteers underwent macro (flow-mediated dilation) and microvascular (muscle oxygen saturation) assessment and blood collection (to measure L-citrulline, L-arginine, nitrate and nitrite) before and after 20 min of blood occlusion in WR, WR + B and placebo conditions. Prolonged ischemia induced endothelial dysfunction in the macro but not in the microvasculature. The WR and WR + B supplementation significantly restored FMD after IR injury compared to the placebo (p < 0.05). However, there was no significant difference between WR and WR + B in the macrovascular function (p > 0.05). Plasma L-citrulline, L-arginine, nitrate, and nitrite significantly increased (p > 0.05) after WR and WR + B supplementation compared to the placebo. A single dose of WR and WR + B effectively minimizes IR-induced macrovascular endothelial dysfunction in healthy individuals. Beetroot co-ingestion with watermelon did not provide an additional effect of endothelial dysfunction induced by IR (NCT04781595, March 4, 2021).

Dietary Arginine and Citrulline Supplements for Cardiovascular Health and Athletic Performance: A Narrative Review

The global market for nutritional supplements (NS) is growing rapidly, and the use of L-arginine (Arg), L-citrulline (Cit), and citrulline malate (CitMal) supplements has been shown to enhance cardiovascular health and athletic performance. Over the past decade, Arg, Cit, and CitMal supplements have received considerable attention from researchers in the field of exercise nutrition, who have investigated their potential effects on hemodynamic function, endothelial function, aerobic and anaerobic capacity, strength, power, and endurance. Previous studies were reviewed to determine the potential impact of Arg, Cit, and CitMal supplements on cardiovascular health and exercise performance. By synthesizing the existing literature, the study aimed to provide insight into the possible uses and limitations of these supplements for these purposes. The results showed that both recreational and trained athletes did not see improved physical performance or increased nitric oxide (NO) synthesis with 0.075 g or 6 g doses of Arg supplement per body weight. However, 2.4 to 6 g of Cit per day for 7 to 16 days of various NSs had a positive impact, increasing NO synthesis, enhancing athletic performance indicators, and reducing feelings of exertion. The effects of an 8 g acute dose of CitMal supplement were inconsistent, and more research is needed to determine its impact on muscle endurance performance. Based on the positive effects reported in previous studies, further testing is warranted in various populations that may benefit from nutritional supplements, including aerobic and anaerobic athletes, resistance-trained individuals, elderly people, and clinical populations, to determine the impact of different doses, timing of ingestion, and long-term and acute effects of Arg, Cit, and CitMal supplements on cardiovascular health and athletic performance.

Supplementation with Nitric Oxide Precursors for Strength Performance: A Review of the Current Literature

Nitric-oxide-stimulating dietary supplements are widely available and marketed to strength athletes and weightlifters seeking to increase muscle performance and augment training adaptations. These supplements contain ingredients classified as nitric oxide (NO) precursors (i.e., "NO boosters"). Endogenous NO is generated via a nitric oxide synthase (NOS)-dependent pathway and a NOS-independent pathway that rely on precursors including L-arginine and nitrates, with L-citrulline serving as an effective precursor of L-arginine. Nitric oxide plays a critical role in endothelial function, promoting relaxation of vascular smooth muscle and subsequent dilation which may favorably impact blood flow and augment mechanisms contributing to skeletal muscle performance, hypertrophy, and strength adaptations. The aim of this review is to describe the NO production pathways and summarize the current literature on the effects of supplementation with NO precursors for strength and power performance. The information will allow for an informed decision when considering the use of L-arginine, L-citrulline, and nitrates to improve muscular function by increasing NO bioavailability.

High-Dose Nitrate Supplementation Attenuates the Increased Blood Pressure Responses to Isometric Blood Flow Restriction Exercise in Healthy Males

The effect of nitrate (NO3−) supplementation on blood pressure (BP) responses during large muscle mass isometric and ischaemic exercise in healthy young adults is unclear. The aim of the present study was to assess the effect of 5-day supplementation of NO3− on BP responses during a short isometric contraction and a sustained ischaemic contraction. In a randomised, double-blinded, crossover design, 14 healthy active young adults underwent BP measurements after 5 days of either NO3− (NIT) or placebo (PLA) supplementation. Beat-by-beat BP was measured at pre- and post-exercise rest, and during a short (20 s) isometric contraction at 25% maximal strength and throughout a sustained ischaemic contraction. Plasma nitrite (NO2−) concentration increased significantly after NO3− supplementation compared to placebo (475 ± 93 nmol·L−1 vs. 198 ± 46 nmol·L−1, p < 0.001, d = 3.37). Systolic BP was significantly lower at pre- (p = 0.051) and post-exercise rest (p = 0.006), during a short isometric contraction (p = 0.030), and throughout a sustained ischaemic contraction (p = 0.040) after NO3− supplementation. Mean arterial pressure was significantly lower at pre- (p = 0.004) and post-exercise rest (p = 0.043), during a short isometric contraction (p = 0.041), and throughout a sustained ischaemic contraction (p = 0.021) after NO3− supplementation. Diastolic BP was lower at pre-exercise rest (p = 0.032), but not at post-exercise rest, during a short isometric contraction, and during a sustained ischaemic contraction (all p > 0.05). Five days of NO3− supplementation elevated plasma NO2− concentration and reduced BP during a short isometric contraction and a sustained ischaemic contraction in healthy adults. These observations indicate that multiple-day nitrate supplementation can decrease BP at rest and attenuate the increased BP response during isometric exercise. These findings support that NO3− supplementation is an effective nutritional intervention in reducing SBP and MAP in healthy young males during submaximal exercise.

Eight Days of L-Citrulline or L-Arginine Supplementation Did Not Improve 200-m and 100-m Swimming Time Trials

The effects of L-citrulline or L-arginine supplementation on exercise performance are equivocal, and the effects on swimming performance are unclear. We aimed to assess whether 8-day supplementation with L-arginine or L-citrulline supplementation would improve 200 m and 100 m freestyle swimming time-trial performances. After the baseline trial (first visit), in a double-blind, randomised design, 15 trained/developmental (5 females) swimmers and triathletes were assigned to three groups and underwent an 8-day supplementation period, with a daily dose of either 8 gr L-arginine (Arg, n = 5) or L-citrulline (Cit, n = 5) or placebo (Pla, n = 5). On day 9, participants completed experimental trial (second visit). In each trial, after blood sampling, participants performed both 200 m and 100 m freestyle swimming time-trials, with 30 min recovery between trials. Plasma nitric oxide (NOx) and blood lactate concentrations (BLa) were collected immediately before and after 200 m and 100 m TTs, respectively. No significant difference was observed in NOx between groups (p = 0.201). There was no significant difference in 200 m (p = 0.226) and 100 m swimming time-trials (p = 0.993) between groups. There was a main effect of time on BLa concentration (p < 0.001), but no trial × group (p = 0.243) and trial × lactate × group interaction effect (p = 0.276) was present. Furthermore, 8-day either L-citrulline or L-arginine supplementation did not enhance middle (200 m) and short-distance (100 m) swimming performance in trained/developmental swimmers and triathletes. These findings do not support the use of L-citrulline or L-arginine supplementation as ergogenic aids for swimming performance.

Effects of inorganic nitrate on ischaemia-reperfusion injury after coronary artery bypass surgery

Background

Nitric oxide (NO) is an important signalling molecule in the cardiovascular system with protective properties in ischaemia–reperfusion injury. Inorganic nitrate, an oxidation product of endogenous NO production and a constituent in our diet, can be recycled back to bioactive NO. We investigated if preoperative administration of inorganic nitrate could reduce troponin T release and other plasma markers of injury to the heart, liver, kidney, and brain in patients undergoing cardiac surgery.

Methods

This single-centre, randomised, double-blind, placebo-controlled trial included 82 patients undergoing coronary artery bypass surgery with cardiopulmonary bypass. Oral sodium nitrate (700 mg×2) or placebo (NaCl) were administered before surgery. Biomarkers of ischaemia–reperfusion injury and plasma nitrate and nitrite were collected before and up to 72 h after surgery. Troponin T release was our predefined primary endpoint and biomarkers of renal, liver, and brain injury were secondary endpoints.

Results

Plasma concentrations of nitrate and nitrite were elevated in nitrate-treated patients compared with placebo. The 72-h release of troponin T did not differ between groups. Other plasma biomarkers of organ injury were also similar between groups. Blood loss was not a predefined outcome parameter, but perioperative bleeding was 18% less in nitrate-treated patients compared with controls.

Conclusion

Preoperative administration of inorganic nitrate did not influence troponin T release or other plasma biomarkers of organ injury in cardiac surgery.

Clinical trial registration

NCT01348971.

Suitability of the muscle O2 resaturation parameters most used for assessing reactive hyperemia: a near-infrared spectroscopy study

Background

There is a spectrum of possibilities for analyzing muscle O₂ resaturation parameters for measurement of reactive hyperemia in microvasculature. However, there is no consensus with respect to the responsiveness of these O₂ resaturation parameters for assessing reactive hyperemia.

Objectives

This study investigates the responsiveness of the most utilized muscle O₂ resaturation parameters to assess reactive hyperemia in the microvasculature of a clinical group known to exhibit impairments of tissue O₂ saturation (StO₂).

Methods

Twenty-three healthy young adults, twenty-nine healthy older adults, and thirty-five older adults at risk of cardiovascular disease (CVD) were recruited. Near-infrared spectroscopy (NIRS) was used to assess StO₂ after a 5-min arterial occlusion challenge and the following parameters were analyzed: StO_{2slope_10s}, StO_{2slope_30s}, and StO_{2slope_until_baseline} (upslope of StO₂ over 10s and 30s and until StO₂ reaches the baseline value); time to StO_2baseline and time to StO_2max (time taken for StO₂ to reach baseline and peak values, respectively); ∆StO_2reperfusion (the difference between minimum and maximum StO₂ values); total area under the curve (StO_2AUCt); and AUC above the baseline value (StO_{2AUC_above_base}).

Results

Only StO_{2slope_10s} was significantly slower in older adults at risk for CVD compared to healthy young individuals (p < 0.001) and to healthy older adults (p < 0.001). Conversely, time to StO_2max was significantly longer in healthy young individuals than in older adult at CVD risk.

Conclusions

Our findings suggest that StO_{2slope_10s} may be a measure of reactive hyperemia, which provides clinical insight into microvascular function assessment.

The Effects of L-Citrulline on Blood-Lactate Removal Kinetics Following Maximal-Effort Exercise

The accumulation of lactate in muscle and blood during high-intensity exercise is negatively correlated with the duration exercise can be sustained. Removal of lactate is a key component of acute recovery between consecutive bouts of such exercise. Low-intensity exercise enhances recovery by accelerating lactate turnover in metabolically active tissues, largely mediated by blood flow to these tissues. Therefore, the purpose of this research was to clarify if L-citrulline, a nutritional supplement purported to promote vasodilation via enhanced nitric oxide availability, would augment the removal of blood lactate during active recovery (AR). L-citrulline ingestion will augment the rate of blood lactate concentration decrease during AR, reduce the oxygen-cost of submaximal exercise, and increase time-to-exhaustion and peak oxygen uptake (V̇O2peak) during a test of maximal aerobic power. Healthy university students (five males & five females) participated in this double-blind, randomized, placebo-controlled study. Participants exercised on a cycle ergometer at submaximal steady-state intensities followed by progressively increasing intensity to exhaustion, 10 min of AR, and then supramaximal intensity exercise to exhaustion. Oxygen uptake was measured throughout the trial and blood lactate was sampled repeatedly during AR. The protocol elicited very high peak blood lactate concentrations after exercise (11.3 + 1.3 mmol/L). L-citrulline supplementation did not significantly alter blood lactate kinetics during AR, the oxygen cost of exercise, V̇O2peak, or time-to-exhaustion. Despite a strong theoretical basis by which L-citrulline could augment lactate removal from the blood, L-citrulline supplementation showed no effect as an exercise-recovery supplement.

Altered microvascular reactivity assessed by near-infrared spectroscopy after hepato-pancreato-biliary surgery

Little is known about microcirculatory dysfunction following abdominal surgeries. This study aimed to evaluate changes in microvascular reactivity (MVR) before and after major abdominal surgery, assessed by near-infrared spectroscopy in conjunction with a vascular occlusion test. This prospective observational study included 50 adult patients who underwent hepato-pancreato-biliary surgery lasting ≥ 8 h. MVR was assessed by tissue oxygen saturation (StO₂) changes in the plantar region of the foot during 3 min of vascular occlusion and subsequent release under general anesthesia before and after surgery. The primary outcome was alteration in the recovery slope of StO₂ (RecStO₂) and recovery time (tM) between the preoperative and postoperative values. Postoperative short-term outcome was represented by the Post-operative Morbidity Survey (POMS) score on the morning of postoperative day 2. After surgery, RecStO₂ was reduced (0.74% [0.58-1.06]/s vs. 0.89% [0.62-1.41]/s, P = 0.001), and tM was longer (57.0 [42.9-71.0] s vs. 41.3 [35.5-56.5] s, P < 0.001), compared to the preoperative values. Macrohemodynamic variables such as cardiac index, arterial pressure, and stroke volume during postoperative measurement did not differ with or without relative MVR decline. In addition, the POMS score was not associated with postoperative alterations in microcirculatory responsiveness. MVR in the plantar region of the foot was reduced after major hepato-pancreato-biliary surgery regardless of macrocirculatory adequacy. Impaired MVR was not associated with short-term outcomes as long as macrocirculatory indices were well maintained. The impact of relative microcirculatory changes, especially combined with inadequate macrocirculation, on postoperative complications remains to be elucidated.Clinical Trial Registrations UMIN-CTR trial ID: 000033461.

Synergetic Effect of NO Precursor Supplementation and Exercise Training

INTRODUCTION

Nitric oxide (NO) precursor supplementation has been shown to increase NO bioavailability and can potentially improve vascular function and exercise performance. It remains unclear whether the combination of NO precursor supplementation and exercise training has synergic effects on exercise performance. This study aims to assess the effect of chronic nitrate and citrulline intake on exercise training adaptations in healthy young individuals.

METHODS

In this randomized, double-bind trial, 24 healthy young (12 females) subjects performed vascular function assessment (blood pressure, pulse wave velocity, postischemia vasodilation, and cerebrovascular reactivity) and both local (submaximal isometric unilateral knee extension) and whole-body (incremental cycling) exercise tests to exhaustion before and after a 2-month exercise training program and daily intake of a placebo or a nitrate-rich salad and citrulline (N + C, 520 mg nitrate and 6 g citrulline) drink. Prefrontal cortex and quadriceps oxygenation was monitored continuously during exercise by near-infrared spectroscopy.

RESULTS

N + C supplementation had no effect on vascular function and muscle and cerebral oxygenation during both local and whole-body exercise. N + C supplementation induced a significantly larger increase in maximal knee extensor strength (+5.1 ± 3.5 vs +0.2 ± 5.5 kg, P = 0.008) as well as a trend toward a larger increase in knee extensor endurance (+35.2 ± 26.1 vs +24.0 ± 10.4 contractions, P = 0.092) than placebo, but no effect on exercise training-induced maximal aerobic performance improvement.

CONCLUSION

These results suggest that chronic nitrate and citrulline supplementation enhances the effect of exercise training on quadriceps muscle function in healthy active young individuals, but this does not translate into improved maximal aerobic performances.

Protective effects of epigallocatechin gallate against ischemia reperfusion injury in rat skeletal muscle via activating Nrf2/HO-1 signaling pathway

AIMS

Previous studies have demonstrated that epigallocatechin gallate (EGCG) had certain protective effects on myocardial and renal ischemia reperfusion (I/R) injury. We aimed to research the special effects and underling mechanisms of EGCG on skeletal muscle I/R injury.

MAIN METHOD

We established an experimental rat model of I/R skeletal muscle injury and treated with different doses of EGCG. Hematoxylin eosin staining, TUNEL assay, ELISA, qRT-PCR and Western blotting were used to evaluate the effects of EGCG.

KEY FINDINDS

EGCG significantly improved skeletal muscle function of I/R injury rats. Moreover, EGCG had positive effects on decreasing apoptosis of skeletal muscle tissues, alleviating oxidative stress damage and suppressing the production of inflammatory cytokines. Further, EGCG had positive effects on activating Nrf2/HO-1 signaling pathway.

SIGNIFICANCE

EGCG might be a powerful candidate compound for alleviating I/R injury in rat skeletal muscle.

Effects of Citrulline Supplementation on Body Weight in Patients With Hepatobiliary Pancreatic Surgery

BACKGROUND

Many health benefits have been proposed for citrulline, but they lack evidence based on human research. This study was to evaluate whether an oral citrulline supplement affects body weight changes and laboratory values in patients with hepatobiliary and pancreatic surgery.

METHODS

Patients who underwent hepatobiliary and pancreatic surgery during January to June 2015 were screened for analysis. Patients using citrulline during hospital stay and at discharge were classified as the citrulline group, whereas those without any records of citrulline were designated as the control group. The primary efficacy outcome was the change in body weight at discharge and at first outpatient visit. Other outcomes included change in laboratory values.

RESULTS

A total of 138 patients were included in analysis. Citrulline group and control group did not differ with respect to baseline characteristics except for white blood cell count. Percent in change of body weight and body mass index from discharge to first outpatient visit was significantly different between the 2 groups, showing less weight loss in citrulline group than in controls (-0.8 ± 2.7% vs -2.5 ± 3.8%, P < 0.05). Especially in men, citrulline use significantly affected weight loss from the multivariate analysis (P < 0.05); percent change in weight in citrulline group was predicted to increase by 2.1 units. During hospital stay, significant differences between the 2 groups were found in changes of cholesterol and protein levels.

CONCLUSION

Citrulline supplement reduced weight loss in surgical patients during recovery.

The effects of the analysis strategy on the correlation between the NIRS reperfusion measures and the FMD response

This study aimed to investigate the correlation between near-infrared spectroscopy (NIRS)-derived measures of microvascular responses using a range of different analysis and flow-mediated dilation (FMD). Additionally, we aimed to investigate whether assessing NIRS and FMD simultaneously or non-simultaneously would affect this association. Thirty-five healthy young individuals (26 ± 13 years old) participated in the study. Twenty were submitted to a simultaneous NIRS/FMD test (NIRS probe placed below the cuff during FMD test) and fifteen to a non-simultaneous FMD and NIRS intervention (NIRS test performed 20 min after FMD). NIRS-derived oxygen saturation signal (StO₂) during reperfusion was analyzed as follow: upslope of a 10 s (slope 10 s) and 30 s (slope 30 s) reperfusion window immediately following cuff deflation, time for the StO₂ to reach the pre-occlusion ₍baseline) values after cuff release (time to baseline) and to reach the peak after cuff release (time to max), difference between the minimum and maximum StO₂ value reached after cuff deflation (Magnitude) and; the total area under the reperfusion curve above the baseline value until the end of the 2 min post cuff release (AUC 2 min). There was a significant positive correlation between slope 10 s and FMD in the simultaneous (r = 0.60; p < 0.05) and non-simultaneous (r = 0.62; p < 0.05) assessments. There was no significant correlation between NIRS-derived slope 30 s, time to baseline, time to max, magnitude, and AUC 2 min and the FMD in both methods. The association between NIRS and FMD is analysis strategy dependent, regardless if assessed simultaneously or non-simultaneously.

Effect of chronic nitrate and citrulline supplementation on vascular function and exercise performance in older individuals

Increased nitric oxide (NO) bioavailability may improve exercise performance and vascular function. It remains unclear whether older adults who experience a decreased NO bioavailability may benefit from chronic NO precursor supplementation. This randomised, double-blind, trial aims to assess the effect of chronic NO precursor intake on vascular function and exercise performance in older adults (60-70 years old). Twenty-four healthy older adults (12 females) performed vascular function assessment and both local (knee extensions) and whole-body (incremental cycling) exercise tests to exhaustion before and after one month of daily intake of a placebo (PLA) or a nitrate-rich salad and citrulline (N+C, 520mg nitrate and 6g citrulline) drink. Arterial blood pressure (BP) and stiffness, post-ischemic, hypercapnic and hypoxic vascular responses were evaluated. Prefrontal cortex and quadriceps oxygenation was monitored by near-infrared spectroscopy. N+C supplementation reduced mean BP (-3.3mmHg; p=0.047) without altering other parameters of vascular function and oxygenation kinetics. N+C supplementation reduced heart rate and oxygen consumption during submaximal cycling and increased maximal power output by 5.2% (p<0.05), but had no effect on knee extension exercise performance. These results suggest that chronic NO precursor supplementation in healthy older individuals can reduce resting BP and increase cycling performance by improving cardiorespiratory responses.

Effects of acute nitric oxide precursor intake on peripheral and central fatigue during knee extensions in healthy men

NEW FINDINGS

What is the central question of this study? What is the effect of acute NO precursor intake on vascular function, muscle and cerebral oxygenation and peripheral and central neuromuscular fatigue during knee-extension exercise? What is the main finding and its importance? Acute NO precursor ingestion increases the plasma concentrations of NO precursors (nitrate, arginine and citrulline) and enhances post-ischaemic vasodilatation, but has no significant effect on muscle and cerebral oxygenation, peripheral and central mechanisms of neuromuscular fatigue and, consequently, does not improve exercise performance.

ABSTRACT

Nitric oxide (NO) plays an important role in matching blood flow to oxygen demand in the brain and contracting muscles during exercise. Previous studies have shown that increasing NO bioavailability can improve muscle function. The aim of this study was to assess the effect of acute NO precursor intake on muscle and cerebral oxygenation and on peripheral and central neuromuscular fatigue during exercise. In four experimental sessions, 15 healthy men performed a thigh ischaemia-reperfusion test followed by submaximal isometric knee extensions (5 s on-4 s off; 45% of maximal voluntary contraction) until task failure. In each session, subjects drank a nitrate-rich beetroot juice containing 520 mg nitrate (N), N and citrulline (6 g; N+C), N and arginine (6 g; N+A) or a placebo (PLA). Prefrontal cortex and quadriceps near-infrared spectroscopy parameters were monitored continuously. Transcranial magnetic stimulation and femoral nerve electrical stimulation were used to assess central and peripheral determinants of fatigue. The post-ischaemic increase in thigh blood total haemoglobin concentration was larger in N (10.1 ± 3.7 mmol) and N+C (10.9 ± 3.3 mmol) compared with PLA (8.2 ± 2.7 mmol; P < 0.05). Nitric oxide precursors had no significant effect on muscle and cerebral oxygenation or on peripheral and central mechanisms of neuromuscular fatigue during exercise. The total number of knee extensions did not differ between sessions (N, 71.9 ± 33.2; N+A, 73.3 ± 39.4; N+C, 74.6 ± 34.0; PLA, 71.8 ± 39.9; P > 0.05). In contrast to the post-ischaemic hyperaemic response, NO bioavailability in healthy subjects might not be the limiting factor for tissue perfusion and oxygenation during submaximal knee extensions to task failure.

l-Citrulline Supplementation: Impact on Cardiometabolic Health

Diminished bioavailability of nitric oxide (NO), the gaseous signaling molecule involved in the regulation of numerous vital biological functions, contributes to the development and progression of multiple age- and lifestyle-related diseases. While l-arginine is the precursor for the synthesis of NO by endothelial-nitric oxide synthase (eNOS), oral l-arginine supplementation is largely ineffective at increasing NO synthesis and/or bioavailability for a variety of reasons. l-citrulline, found in high concentrations in watermelon, is a neutral alpha-amino acid formed by enzymes in the mitochondria that also serves as a substrate for recycling l-arginine. Unlike l-arginine, l-citrulline is not quantitatively extracted from the gastrointestinal tract (i.e., enterocytes) or liver and its supplementation is therefore more effective at increasing l-arginine levels and NO synthesis. Supplementation with l-citrulline has shown promise as a blood pressure lowering intervention (both resting and stress-induced) in adults with pre-/hypertension, with pre-clinical (animal) evidence for atherogenic-endothelial protection. Preliminary evidence is also available for l-citrulline-induced benefits to muscle and metabolic health (via vascular and non-vascular pathways) in susceptible/older populations. In this review, we examine the impact of supplementing this important urea cycle intermediate on cardiovascular and metabolic health outcomes and identify future directions for investigating its therapeutic impact on cardiometabolic health.