Signs and Symptoms

Many times, people with atherosclerosis do not have any symptoms until an artery is 40% clogged with plaque. Symptoms vary depending upon which arteries are affected.

Coronary Artery Disease

Symptoms of coronary artery disease (where the heart arteries narrow) are usually brought on by physical exercise, sexual activity, exposure to cold weather, anger, or stress. Common symptoms include:

• Chest pain (generally a heavy, squeezing, or crushing sensation with possible burning or stabbing pains)
• Abdominal, neck, back, jaw, or shoulder/arm pain
• Weakness
• Perspiration
• Shortness of breath

Cerebrovascular Disease

Cerebrovascular disease (where the arteries that supply the brain with blood are narrowed) can cause transient ischemic attack (a sudden loss of brain function with complete recovery within 24 hours) and stroke. Symptoms may include:

• Weakness or paralysis on one side of the body
• Trouble speaking or understanding speech
• Loss of vision in one eye
• Muscle weakness
• Sudden trouble walking
• Dizziness
• Loss of balance or coordination
• Sudden severe headache

Peripheral Artery Disease

Peripheral artery disease affects the arteries that supply the arms and legs with oxygen-rich blood. Symptoms may include:

• Pain, aching, cramps, numbness, or sense of fatigue in the leg muscles (intermittent claudication)
• "Bruits" (blowing sounds your doctor can hear with a stethoscope that indicate turbulence in blood flow)
• Hair loss
• Thickened nails
• Smooth, shiny skin surface
• Skin that is cold to the touch
• Gangrene

What Causes It?

No one knows the exact cause of atherosclerosis, although they do know what causes it to get worse. Many researchers believe it begins with an injury to the innermost layer of the artery, known as the endothelium. Researchers believe the following factors contribute to the damage:

• High blood pressure
• Elevated LDL ("bad") cholesterol
• An accumulation of homocysteine. An amino acid produced by the human body, thought to be a risk factor for heart disease, stroke, osteoporosis, diabetes, and dementia.
• Smoking
• Diabetes
• Inflammation
• Overweight or obesity
• Unhealthy diet
• Lack of exercise
• Family history of heart disease

Once the artery is damaged, blood cells called platelets build up there to try and heal the injury. Over time, fats, cholesterol, and other substances also build up at the site, which thickens and hardens the artery wall. The blood flow through the artery is decreased, and the oxygen supply to organs also decreases. Blood clots may form, blocking the artery and cutting off blood supply to other organs.

Some people do not have the classic risk factors of atherosclerosis (such as cigarette smoking and high blood pressure). It is possible that there may be other causes, such as an infection. Research is ongoing.

Risk Factors

Risk factors for atherosclerosis may include:

• Being male
• If female, being past menopause
• High blood pressure
• High LDL ("bad") cholesterol or triglycerides (fats in the blood)
• Low HDL ("good") cholesterol
• Diabetes
• Being overweight
• Smoking
• A family history of heart disease, stroke, or arterial disease 
• Elevated homocysteine levels
• Sedentary lifestyle
• Diets high in saturated fat and trans fatty acids (trans fats)
• Depression
• Obstructive sleep apnea

What to Expect at Your Doctor's Office

Your doctor can determine your risk for heart disease by conducting certain tests. Blood tests can show high levels of cholesterol, homocysteine, and bloodclotting factors.

A stress test (also known as an exercise tolerance test) monitors your heart rate and blood pressure while you walk on a treadmill or ride a stationary bicycle. An electrocardiogram (ECG) is used during a stress test to detect abnormal heart rhythms, scar tissue in the heart muscle from a prior heart attack, and areas of decreased blood flow to the heart.

Imaging techniques used during a stress test (such as an ultrasound) can pinpoint areas where blood flow to the heart may be reduced. An angiogram (or angiography), where your doctor injects a dye into your arteries and then performs a chest x-ray, can reveal areas of damage and plaque buildup.

Preventive Care

Leading a healthy lifestyle can help prevent atherosclerosis.

• Stop smoking.
• Exercise at least 30 minutes a day, 6 days a week.
• Eat healthy foods, such as fruits, vegetables, and whole grains that are low in saturated fat and high in fiber.
• Maintain a normal weight (or lose weight if you need to).
• Reduce stress.
• If you have high blood pressure, high cholesterol, diabetes, or another chronic condition, work with your doctor to keep it in check.
• Talk to your doctor about adding supplements to your diet.

Treatment Options

Healthy lifestyle choices are important in preventing and treating atherosclerosis. Your doctor may prescribe drugs to lower your cholesterol or blood pressure and to prevent complications. Nutrition and dietary supplements may help reduce your risk when used along with certain medications. Some herbs have also shown promise in lowering cholesterol levels and reducing the risk of heart disease.

Drug Therapies

Cholesterol Lowering Drugs

If, after making adjustments to your diet and exercise habits, your LDL cholesterol remains high, your doctor may prescribe medications to lower it. If your cholesterol is extremely high (more than 200 mg/dL), you may start drug therapy at the same time you make lifestyle changes. Drugs commonly used to treat high cholesterol include:

Statins: These are usually the drugs of choice as they are easy to take and have few interactions with other drugs. But, studies suggest that statins reduce cardiovascular events by only 20 to 30%, leaving at least 70% of the events to continue occurring. Side effects can include myositis (inflammation of the muscles), joint pain, stomach upset, and liver damage. People who are pregnant or have liver disease should not take statins. Statins include:

• Lovastatin (Mevachor)
• Pravastatin (Pravachol)
• Rosuvastatin (Crestor)
• Simvastatin (Zocor)
• Atorvastatin (Lipitor)
• Fluvastatin (Lescor)

Niacin (nicotinic acid): In prescription form, niacin is sometimes used to lower LDL cholesterol. It can be more effective in raising HDL cholesterol than other medications. Side effects may include redness or flushing of the skin (which can be reduced by taking aspirin 30 minutes before the niacin), stomach upset (which usually subsides within a few weeks), headache, dizziness, blurred vision, and liver damage. Dietary supplements of niacin should not be used instead of prescription niacin, as it can cause side effects. Only take niacin for high cholesterol under a doctor's supervision.

Bile acid sequestrants: These are used to treat high levels of LDL. Common side effects include bloating, constipation, heartburn, and elevated triglycerides. People who have high levels of triglycerides (fats in the blood) should not take bile acid sequestrants. These drugs include:

• Cholestyramine (Prevalite, Questran)
• Colestipol (Colestid)
• Colesevelam (WelChol)

Cholesterol absorption inhibitors: The medication ezetimibe (Zetia) limits how much LDL cholesterol can be absorbed in the small intestine. Side effects include headaches, nausea, muscle weakness. Ezetimibe is combined with simvastatin in the drug Vytorin.

Fibric acid derivatives: These medicines are effective at lowering triglyceride levels, and moderately effective at lowering LDL. They are used to treat high triglycerides and low HDL in people who cannot take niacin. Side effects include myositis, stomach upset, sun sensitivity, gallstones, irregular heartbeat, and liver damage.

• Gemfibrozil (Lopid)
• Fenofibrate (Tricor, Lofibra)

If you do not respond to one class of drugs, you doctor may use a combination of drugs from 2 classes.

Blood Pressure Lowering Drugs

Among the drugs used to lower blood pressure are:

Beta blockers: Beta blockers slow down the heart rate (reducing the workload on the heart) and reduce stress hormones in the body (which allows blood vessels to relax). Beta blockers alone do not work as well in African-Americans, but they are effective when combined with a thiazide diuretic. Beta blockers include:

• Atenolol (Tenormin)
• Bisoprolol (Zebeta)
• Metoprolol (Lopressor, Toprol XL)
• Nadolol (Corgard)
• Timolol (Blocadren)
• Nebivolol (Bystolic)

Angiotensin converting enzyme (ACE) inhibitors: ACEs block the chemical angiotensin from forming in the body, helping prevent blood vessels from narrowing. As blood vessels relax, blood pressure is lowered. Like beta blockers, ACE inhibitors alone do not work as well in African-Americans, but are effective when combined with a thiazide diuretic. ACE inhibitors include:

• Captopril (Capoten)
• Benazepril (Lotensin)
• Enalapril (Vasotec)
• Lisinopril (Prinivil, Zestril)
• Fosinopril (Monopril)
• Ramipril (Altace)
• Perindopril (Aceon)
• Quinapril (Accupril)
• Moexipril (Univasc)
• Trandolapril (Mavik)

Calcium channel blockers: Calcium channel blockers relax blood vessels and lower blood pressure by blocking calcium from entering heart cells and arteries. Side effects may include constipation, nausea, and headache. Grapefruit juice interacts with some calcium channel blockers, so avoid it if you take these drugs. Calcium channel blockers include:

• Amlodipine (Norvasc)
• Bepridil (Vascor)
• Diltiazem (Cardizem)
• Felodipine (Plendil)
• Nifedipine (Adalat, Procardia)
• Nicardipine (Cardene)
• Verapamil (Calan, Isoptin)

Angiotensin II receptor blockers (ARBs): ARBs block the effects of the chemical angiotensin in the body, lowering blood pressure. ARBs are sometimes used when a person cannot take ACE inhibitors. These drugs include:

• Candesartan (Atacand)
• Eprosartan (Tevetan)
• Irbesartan (Avapro)
• Losartan (Cozaar)
• Telmisartan (Mycardis)
• Valsartan (Diovan)

Diuretics: Diuretics help the kidneys get rid of sodium and water from the body. This decreases the volume of blood in the body and lowers blood pressure. There are 3 types of diuretics: thiazide, loop, and potassium-sparing.

• Thiazide diuretics may lower potassium levels and may increase cholesterol and blood sugar. Hydrocholorothiazide is the most common of these.
• Loop diuretics also tend to lower potassium levels. Furosemide (Lasix) and bumetanide (Bumex) are loop diuretics.
• Potassium-sparing diuretics do not lower potassium. Amiloride (Midamor) and triamterene (Maxzidel) are in this class.

Sometimes drugs from these classes may be combined.

Blood-Thinning Drugs

Blood-thinning drugs, antiplatelet agents and anticoagulants, are used to keep blood clots from forming. They include:

• Aspirin, reduces risk of transient ischemic attack (TIA), stroke, and heart attacks
• Ticlodipine, for people who cannot take aspirin (due to allergies, for example), or do not improve from aspirin; has more side effects than aspirin
• Dipyridamole, not as effective as aspirin when used alone, but may be used in combination with aspirin or warfarin (Coumadin)
• Clopidogrel (Plavix) reduces risk of heart attacks
• Glycoprotein IIb/IIIa receptor agonists, such as abciximab, eptifibatide, lamifiban, and tirofiban, used when awaiting or just following an angioplasty
• Heparin, anticoagulant; given by injection
• Warfarin (Coumadin), often used after a heart attack

Surgery and Other Procedures

Several different procedures (surgical and nonsurgical) may be performed depending upon which arteries are narrowed and how much they are blocked.

Nonsurgical techniques

• Angioplasty. Used to widen narrowed arteries. A surgeon inserts a catheter with a deflated balloon into the narrowed part of the artery. The balloon is inflated, widening the blood vessel so blood can flow more easily. The balloon is then deflated, and the catheter is removed. A permanent stent (wire mesh) may be put in to hold the artery open and improve blood flow.
• Atherectomy. A procedure to remove plaque from the arteries. It uses a laser catheter or a rotating shaver.

Surgical Procedures

• Bypass surgery. A surgeon uses a blood vessel from another part of your body or an artificial tube to reroute blood around clogged arteries.
• Minimally invasive bypass surgery. Uses a small incision rather than the broad opening in the chest wall created during regular bypass surgery.
• Endarterectomy. Used to remove plaque in the carotid (neck) or peripheral arteries.

Complementary and Alternative Therapies

Healthy eating habits can help reduce high cholesterol, high blood pressure, and obesity, three major risk factors for heart disease. The American Heart Association (AHA) has developed dietary guidelines to help lower fat and cholesterol intake and reduce the risk of heart disease. The AHA does not recommend very low-fat diets because research shows that unsaturated ("good") fats, such as those found in olive oil and avocados have health benefits.

Many fad diets are popular, but they may not help you lose weight and keep it off, and in some cases, they may not even be healthy. Any healthy diet will include a variety of foods. If a diet bans an entire food group (such as carbohydrates), it is probably not healthy.

For healthy eating, the AHA recommends a balanced diet that contains the following:

• Grains: 6 to 8 servings per day (half should be whole grains)
• Vegetables: 3 to 5 servings per day
• Fruits: 4 to 5 servings per day
• Fat free or low fat dairy: 2 to 3 servings per day
• Lean meat, poultry, seafood: 3 to 6 oz. per day (about the size of a deck of cards)
• Fats and oils: 2 to 3 tbsp. per day (use unsaturated fats such as olive oil or canola oil)
• Nuts, seeds, legumes: 3 to 5 servings per week
• Sweets, sugars: 5 or fewer servings per week (the fewer, the better)

In addition, the AHA also recommends eating 2 servings of fatty fish (such as salmon or lake trout) per week; holding sodium (salt, including salt already added to food) to less than 2,400 mg per day; and limiting alcohol intake to 1 drink a day for women and 2 for men.

Diets for People with High Blood Pressure

People with high blood pressure especially need to lower the amount of sodium in their diet. The DASH diet (Dietary Approaches to Stop Hypertension) emphasizes a diet rich in fruits, vegetables, and low-fat or nonfat dairy products that provide high intake of potassium, magnesium, and calcium. Sodium intake should be between 1,500 to 2,400 mg per day (the lower, the better). Weight loss, regular physical activity, and limiting alcohol are also important factors for lowering blood pressure.

Mediterranean Diet

The Mediterranean-style diet concentrates on whole grains, fresh fruits and vegetables, fish, olive oil, and moderate, daily wine consumption. The Mediterranean-style diet is not low fat. Instead, it is low in saturated fat but high in monounsaturated fat. It appears to be heart healthy. In a long-term study of 423 people who had a heart attack, those who followed a Mediterranean-style diet had a 50 to 70% lower risk of recurrent heart disease compared with people who received no special dietary counseling.

The TLC (Therapeutic Lifestyle Changes) Diet

This diet is recommended for people who have high cholesterol. With the TLC diet, less than 7% of your daily total calories should come from saturated fat, and only 25% to 35% of your daily calories should come from total fat. Sodium should be limited to 2,400 mg per day. If these steps do not lower your cholesterol, your doctor may suggest adding more soluble fiber to your diet, along with plant sterols (found in cholesterol-lowering margarines and salad dressings).

Supplements and Vitamins

Talk with your doctor before taking any vitamins, minerals, or supplements to make sure they are right for you; to establish the proper dose for your condition; and to make sure they do not interact with any prescription drugs, herbs, or supplements you also might be taking.

Folic acid (400 mcg per day), vitamin B6 (25 to 100 mg per day), vitamin B12 (2 to 100 mcg per day): B vitamins help the body break down homocysteine, an amino acid that has been linked to increased risk of heart disease and stroke. Researchers think that homocysteine may also contribute to atherosclerosis by damaging artery walls, thus causing blood clots to form, but so far they have not found a definite link. Researchers also do not yet know whether taking B vitamins reduces the risk of atherosclerosis or heart disease, nor do they know how much might have an effect. However, recent studies suggest that high-dose B vitamin supplementation significantly reduces the progression of early stage subclinical atherosclerosis. If you have several risk factors for heart disease, talk to your doctor about checking your homocysteine levels and ask whether you should take a B complex vitamin supplement. In the meantime, be sure to get enough B vitamins by eating fruits and leafy green vegetables every day. When selecting folic acid supplements, choose products that contain natural rather than synthetic folic acid. In 2010, some controversy emerged about folic acid with some scientists claiming adverse effects from high doses of folic acid over long periods of time and others disputing these claims. Folic acid also potentially interacts with many medications. Work with your physician to determine if and how much supplementation may be right for you.

Omega-3 fatty acids, found in fish oil (1 to 4 g per day): There is solid evidence that omega-3 fatty acids (namely EPA and DHA) found in fish oil can help protect against atherosclerosis by preventing the development of plaque and blood clots. Omega-3s can also help prevent heart disease, lower blood pressure, and reduce the level of triglycerides (fats) in the blood. One preliminary study found that people with high cholesterol who took fish oil and red yeast rice lowered cholesterol levels about as much as people who took simvastatin (Zocor). The AHA recommends that people eat at least 2 servings of fatty fish (such as salmon) per week. People with heart disease, or those who need to lower their triglyceride levels, may need to take fish oil supplements. Because fish oil at high doses can increase the risk of bleeding, talk to your doctor before taking an omega-3 supplement, especially if you already take blood-thinning medication.

Beta-sitosterol (800 mg to 6g per day in divided doses about 30 minutes before meals): Beta-sitosterol is a plant sterol, a compound that can stop cholesterol from being absorbed by the intestines. Several well-designed scientific studies show that beta-sitosterol lowers "bad" LDL cholesterol levels in the body. Beta-sitosterol may lower the amount of vitamin E and beta-carotene absorbed by the body, so ask your doctor if you need to take extra E or beta-carotene. Take caution if you are using Pravastastin (Pravachol) or Ezetimibe (Zetia). Talk to your doctor.

Potassium: Your body needs potassium to keep electrolytes balanced and for nerves to function properly. Some diuretics may cause the body to get rid of too much potassium while other diuretics may increase potassium in the body. Check with your doctor before taking a potassium supplement if you take a diuretic. High levels of potassium can be dangerous. Potassium can also interact with certain blood pressure medications. Speak with your doctor.

Policosanol (5 to 10 mg, 2 times per day): Policosanol is a mix of waxy alcohols usually derived from sugar cane and yams. Several studies have indicated it may lower "bad" LDL cholesterol and possibly even raise "good" HDL cholesterol. One study found that policosanol was equivalent to fluvastatin (Lescol) and simvastatin (Zocor) in lowering cholesterol levels. It may also stop blood clots from forming. However, most studies have been conducted in Cuba by a research group that uses a proprietary form of policosanol and is funded by the manufacturer, so it is hard to evaluate the evidence. Policosanol may increase the risk of bleeding, and should not be taken by people who also take blood-thinning medication.

Antioxidant vitamins (beta-carotene, C, and E): Some large, observational studies suggest that people who consume more antioxidant vitamins have a lower risk of heart disease than those who consume lower amounts. However, no studies have shown a cause and effect relationship.

• Beta-carotene. While some studies suggest that eating a diet high in beta-carotene (found in yellow, orange, and dark green vegetables) may protect against atherosclerosis, other studies show it may increase the risk for people who smoke or drink a lot of alcohol. Researchers think that eating vegetables with beta-carotene provides the body with other antioxidants that may have a protective effect, while just taking a supplement does not.
• Vitamin C. Several studies suggest that eating a diet high in vitamin C can help protect against heart disease, but there is no evidence that taking extra vitamin C through a supplement will help.
• Vitamin E. One randomized, placebo-controlled study failed to show any reduction in heart disease among people who took vitamin E. However, researchers are still studying the effects of vitamin E on heart disease risk. If you have a condition, such as heart disease or diabetes, DO NOT take doses of 400 IU/day or more. Some research suggests that high doses might increase the chance of death from all causes and possibly cause other serious side effects. The higher the dose, the greater the risk of serious side effects. There is contradictory information about the effect of vitamin E on the chance of developing prostate cancer. Some research suggests that taking large amounts of a multivitamin plus a separate vitamin E supplement might actually increase the chance of developing prostate cancer in some men. Several medications, including but not limited to blood-thinning medications and cancer medications, can interact with vitamin E. Talk to your doctor.

Selenium (100 to 200 mcg per day): Some studies show that people who consume more selenium in their diet have a lower risk of heart disease, but again, researchers have not shown a cause and effect relationship. One study even found that taking selenium for a long time significantly increased the risk of developing type 2 diabetes. There is a suggestion in the literature that selenium supplementation may decrease sperm motility and therefore negatively affect fertility in men. Selenium can interfere with many medications, including but not limited to blood-thinning medications and barbituates. Talk to your doctor before taking extra selenium.

Coenzyme Q10 (CoQ10): Researchers believe that CoQ10 may boost blood levels of antioxidants. One study found that people who received daily CoQ10 supplements within 3 days of a heart attack were much less likely to experience subsequent heart attacks and chest pain. They were also less likely to die of the condition than those who did not receive the supplements. Still, more research is needed to say whether CoQ10 has any role in preventing or treating atherosclerosis. People who take statins may have lower amounts of CoQ10 in their bodies and may consider taking a supplement. If you take statins, ask your doctor if you need a CoQ10 supplement. CoQ10 can interact with certain high blood pressure medications, certain cancer medications, and blood-thinning medications, such as warfarin (Coumadin).

Polyphenols: Polyphenols are chemical substances found in plants that have antioxidant properties. Test tube, animal, and some population-based studies suggest that the flavonoids quercetin, resveratrol, and catechins (all found in high concentration in red wine) may help reduce the risk of atherosclerosis by protecting against the damage caused by LDL cholesterol. More studies are needed to confirm these findings.

One study of resveratrol in mice found that it protected against age-related damage to vital organs, including the heart and liver, even when the mice ate a high fat diet. Although this study is promising, researchers need to confirm its findings and to determine whether resveratrol would have the same effect in humans. No one is sure how much resveratrol you would need to experience benefits. In addition, resveratrol may have estrogen-like effects, and researchers do not yet know whether it would pose the same risks as estrogen supplements.

Vitamin D: Preliminary studies suggest that vitamin D may help protect against heart disease, but researchers are not sure why. One observational study found that women over the age of 65 who took vitamin D supplements to protect against osteoporosis had one-third less risk of dying from heart disease as women who did not take the supplements. Another study found that vitamin D deficiency was associated with an increased risk of heart disease, especially among people with high blood pressure. Vitamin D may interact with certain medications. Speak with your doctor.

• Hawthorn. Hawthorn contains the polyphenols rutin and quercetin, and was used traditionally to treat cardiovascular diseases. Animal and laboratory studies show that hawthorn has antioxidant properties that help protect against the formation of plaques and may help lower high cholesterol and high blood pressure. Talk to your doctor before taking hawthorn, as it can interact with other drugs taken for heart disease and high blood pressure and may not be right for certain cardiac conditions.
• Garlic (Allium sativum, 900 mg per day of garlic powder, standardized to 0.6% allicin). Clinical trials have shown that fresh garlic and garlic supplements may lower cholesterol levels, prevent blood clots, and destroy plaque. However, other studies show mixed evidence, and one 2007 study showed no effect at all. Garlic can increase the risk of bleeding and should not be taken if you are also taking blood-thinning medication. Garlic can interfere with certain drugs used in HIV treatment and other medications, possibly including birth control medications and other drugs. Speak with your doctor.
• Olive leaf extract(Olea europaea). One study found that taking olive leaf extract lowered cholesterol and blood pressure among people with mild high blood pressure compared to those who took placebo. More research is needed to confirm these findings.
• Red yeastor red yeast rice (Monascus purpureus). Several studies indicate that a proprietary form of red yeast (Cholestin) can lower cholesterol levels, and that the herb acts like statin drugs (See "Medications" section). For that reason, you should not take red yeast without a doctor's supervision, especially if you already take statins to lower cholesterol.
• Psyllium (Plantago psyllium). Taking psyllium, a type of fiber, helps lower cholesterol levels as well as blood sugar levels. If you take medicine for diabetes, talk to your doctor before taking psyllium.
• Guggul (Commiphora mukul). Guggul is used in Ayurvedic medicine to treat high cholesterol levels. Scientific studies have found mixed results; guggul appears to work in Indian populations, but not in people who eat Western-style, high-fat diets. Guggul may have estrogen-like effects and therefore may be of concern in people with hormone-related cancers or taking hormone medications, such as birth control drugs. Guggul may interact with many medications, including but not limited to blood-thinning medications. Talk to your doctor.

Acupuncture may help reduce risk factors for heart disease. It can help people who want to quit smoking. Some studies indicate that it may aid in weight loss, as well as help lower cholesterol and blood pressure.

Although few studies have examined the effectiveness of specific homeopathic remedies, professional homeopaths may recommend appropriate treatments to reduce the risk of atherosclerosis based on their knowledge and experience. Homeopathic prescriptions for atherosclerosis may include remedies to lower high blood pressure and cholesterol. Before prescribing a remedy, homeopaths take into account a person's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for each individual.

Other Considerations

Prognosis and Complications

Some complications of atherosclerosis may include:

• Heart disease
• Heart failure
• Abnormal heart rhythms
• Stroke
• Heart attack
• Poor blood supply to certain parts of the body (such as the legs or intestines)
• Kidney failure
• Death

The outlook for atherosclerosis varies from person to person. People with atherosclerosis should work closely with their doctors to make appropriate lifestyle changes and, if needed, take the proper medications to control their condition and avoid complications.

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