While a handful of age-old recommendations like eating well and exercising undoubtedly boost a patient’s health profile, there’s one factor nobody can avoid: aging. Chronological age is the primary risk factor for cardiovascular disease (CVD), first author Kristen Nowak, PhD, and colleagues wrote in a recent Hypertension review, and it’s important to take the necessary steps to achieve healthy vascular aging (HVA)—especially if you know you’re at risk for CVD.

These are the four keys to HVA:

1. Aerobic exercise

The connection between aerobic exercise—like spinning, running, swimming or walking—and HVA was first uncovered in 1993, Nowak et al. wrote, when the Baltimore Longitudinal Study of Aging proved the efficacy of exercise in reducing arterial stiffness. In middle-aged to older adults with an otherwise clean bill of health, aerobic exercise can be key to achieving and maintaining HVA.

Results were different in adults with hypertension, the authors wrote. A recent meta-analysis of 14 aerobic exercise trials revealed exercise to be an ineffective defense against arterial stiffness in both prehypertensive and hypertensive adults, which was consistent with previous research.

Though the evidence tying aerobic exercise to HVA is strong for healthy individuals, Nowak and co-authors said, there’s a catch—while increasing time on the treadmill seems to help arterial stiffness, resistance training doesn’t.

2. Weight loss and energy intake

Restricting calorie intake might be tough, but it’s a tried-and-true method for maintaining HVA, Nowak and colleagues said. Studies have consistently proven that short-term caloric restriction—sometimes for a period of less than a month, sometimes for as long as a year—in conjunction with things like sodium reduction, exercise and adhering to the DASH diet reduces both systolic blood pressure (SBP) and carotid-femoral pulse wave velocity (CFPWV).

These strategies are especially effective in overweight or obese adults, the authors wrote, but maintaining lifelong caloric restriction is a “large challenge” and can sometimes result in loss of lean muscle and bone density.

3. Dietary components and patterns

Though Nowak et al. wrote there are some knowledge gaps on the topic, we’ve known that reducing dietary sodium results in lower CFPWV since the ’80s. There’s also evidence that flavonoids—like grapefruit juice, citrus fruits, cocoa, red wine, tea, olive oil and seeds—can reduce CFPWV regardless of changes in a patient’s SBP.

Diets high in fruits and vegetables generally see better results when it comes to HVA, according to the review. One longitudinal study that lasted 27 years showed that kids who consumed copious vegetables in their youth were more likely to continue to eat fresh produce as adults.

4. Pharmacology

The best antihypertensive drugs on the market might be angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ARBs), according to research. Both agents have proven successful in lowering CFPWV, though their contemporaries, including beta blockers, vasodilators, calcium channel blockers and diuretics, have also been shown to have some effect on CFPWV.

Statins have also been reliable CFPWV-lowerers, especially when taken in combination with an ARB.

“Statins have a well-established safety profile, although similar to antihypertensive agents, adherence can be suboptimal, particularly with advancing age,” the authors wrote.

Other potential novel therapies to achieve HVA include AMPK activator metformin, mTOR inhibitors, sirtuin activators and anti-profinflammatory cytokine therapies.

Read Nowak and colleagues’ full review here.