Microorganisms in the body may contribute to destabilisation of coronary plaques and subsequent heart attack


Microorganisms in the body may contribute to destabilisation of coronary plaques and subsequent heart attack, according to late breaking research presented today at ESC Congress 2019 together with the World Congress of Cardiology.

The study found that unlike gut bacteria, the bacteria in coronary plaques were pro-inflammatory.

In addition, patients with acute coronary syndrome (heart attack) had different bacteria in their guts compared to patients with stable angina.

Diet, smoking, pollution, age, and medications have a major impact on cell physiology, the immune system, and metabolism.

Previous research indicates that these effects are mediated by microorganisms in the intestinal tract.

This study investigated the contribution of the microbiota to the instability of coronary plaques.

The study enrolled 30 patients with acute coronary syndrome and ten patients with stable angina.

The researchers isolated gut bacteria from faeces samples.

Coronary plaque bacteria were extracted from angioplasty balloons.

Comparison of microbiota in faeces and coronary plaques revealed a different composition in the two sites. 3

While faecal bacteria had a heterogeneous composition, and a pronounced presence of Bacteroidetes and Firmicutes, coronary plaques primarily contained microbes with pro-inflammatory phenotypes belonging to Proteobacteria and Actinobacteria.

First author Eugenia Pisano, of the Catholic University of the Sacred Heart, Rome, Italy said:

“This suggests a selective retention of pro-inflammatory bacteria in atherosclerotic plaques, which could provoke an inflammatory response and plaque rupture.”

The analyses also revealed differences in gut microbiota between the two groups of patients.

Those with acute coronary syndrome had more Firmicutes, Fusobacteria and Actinobacteria, while Bacteroidetes and Proteobacteria were more abundant in those with stable angina.

Ms Pisano said:

“We found a different make-up of the gut microbiome in acute and stable patients.

The varying chemicals emitted by these bacteria might affect plaque destabilisation and consequent heart attack.

Studies are needed to examine whether these metabolites do influence plaque instability.”

She noted that to date, research has not convincingly shown that infections and the ensuing inflammation are directly involved in the process of plaque instability and heart attack onset.

As an example, antibiotics against Chlamydia Pneumoniae failed to reduce the risk of cardiac events.

But she said: “While this is a small study, the results are important because they regenerate the notion that, at least in a subset of patients, infectious triggers might play a direct role in plaque destabilisation.

Further research will tell us if antibiotics can prevent cardiovascular events in certain patients.”

Ms Pisano concluded: “Microbiota in the gut and coronary plaque could have a pathogenetic function in the process of plaque destabilisation and might become a potential therapeutic target.”

Cardiovascular diseases (CVDs) have become a major health problem because of the associated high morbidity and mortality among patients.123 Over the recent years, the gut microbiota has been found to be linked with multiple diseases, such as obesity,4 diabetes mellitus,5 digestive system diseases67 and cancers.8 Emerging data indicate the relationship between gut microbiota and CVD.91011 There are few microbes in the gut before an infant is born.12 The body is constantly stimulated by the outside world from birth onwards and the number of microorganisms in the intestinal tract begins to increase, gradually forming the dynamic balance of the gut microbiota.13 When dietary habits, environmental factors, intestinal infection or other factors lead to alterations in the species and quantity of intestinal microorganisms in the adult gut, gut dysbiosis takes place, causing inflammation and metabolic disorders, thus promoting the development of CVD. Bacterial gene sequencing, bioinformatics analysis and metabolomics can help researchers better study the structure and functions of the intestinal microflora and possible signalling pathways that the intestinal microflora may be associated with the development of certain diseases.12 In this review, we summarize the roles, mechanisms and therapies associated with the gut microbiota in several common CVDs.Go to:


‘Gut microbiota’ is the umbrella term for the large number of microorganisms that are dependent on the human gut and help the host complete multiple physiological and biochemical functions accompanied by their metabolites. As previously reported, the gastrointestinal tract is known to be home to more bacteria than any other part of the human body.14 The composition of the gut microbiota in different anatomical locations of the gut does not change significantly. Eckburg et al performed metagenomic analysis to determine that the gut microbial community consists of six families, namely the Firmicutes, Bacteroidetes, Proteobacteria, Actino‐bacteria, Fusobacteria and Verrucomicrobia phyla, the majority of which are anaerobic organisms.15 In the healthy bacterial community, the phyla Firmicutes and Bacteroidetes are the main dominant flora, accounting for more than 90% of the total population.16 Unlike the composition of the intestinal microflora, the numbers of microbes residing in different regions of the gut vary greatly. The ascending colon has the highest number of microorganisms, followed by the distal ileum with 1011 cells/g and 107‐8 cells/g microorganisms respectively. The content in the proximal ileum and jejunum is less, only 102‐3 cells/g.17 The host provides a proper environment and essential nutrients for the intestinal microflora. In turn, the intestinal microflora is involved in the regulation of various human functions, such as providing metabolic nutrition to the host, participating in growth promotion and immune regulation, eliminating pathogenic microorganisms and maintaining the integrity of intestinal barriers and normal homeostasis.18Intestinal microbial ecology can be affected by improper dietary patterns, high stress, life events and use of antibiotics, leading to gut dysbiosis.12


Coronary artery disease

The composition and functions of the gut microbiome are affected by external factors that are associated with increased CVD risks, including aging, obesity, a sedentary lifestyle and dietary patterns. In turn, the composition of the gut microbiome may affect the development of CVD.19The observation that DNA from various species of bacteria is found in atherosclerotic lesions and in the gut of the same individuals suggests the gut microbiota may be a potential source of atherosclerotic bacteria and is therefore likely to participate in the pathogenesis of coronary artery disease.2021 Jie et al demonstrated the relationship between the gut microbiota and atherosclerotic CVD.9 They identified that the composition of gut microbiome, including members of the Enterobacteriaceae and Streptococcus spp, was higher in atherosclerotic CVD than in the healthy controls.9 Karlsson et al used shotgun sequencing of the gut metagenome to reveal that intestinal microbial communities in patients with symptomatic atherosclerosis were different from those in healthy controls.22 Patients had increased numbers of the genus Collinsella, while the gender‐ and age‐matched controls had an increased abundance of Eubacterium and Roseburia. 22 Other evidence in humans also implicated the role of the gut microbiota in the development of atherosclerosis.2324

In addition to these studies in humans, there are a series of animal studies. Chan et al established atherosclerotic models by feeding apolipoprotein E knockout (ApoE−/−) mice a high‐fat diet for 12 weeks supplemented with Lactobacillus rhamnosus GG (LGG) or telmisartan (TLM).25 Both supplements changed the proportion of the gut microbiota and reduced the atherosclerotic plaque size significantly. Furthermore, five species (EubacteriaAnaeroplasmaRoseburiaOscillospiraand Dehalobacteria) have been shown to be effective in preventing atherosclerosis. Similarly, experiments performed by Stepankova et al demonstrated the protective effects of intestinal bacteria on the progression of atherosclerotic lesions.26 They fed germ‐free ApoE−/− mice a low‐ or high‐cholesterol diet for 3‐4 months. Atherosclerotic plaques were detected in the aorta of germ‐free mice fed the low‐cholesterol diet. Their study supports the protective effect of bacteria on atherosclerosis. Conversely, Kasahara et al showed that the absence of microbiota could cause an increase in atherosclerotic lesion formation compared with conventionally raised controls.27 Other bacteria, including Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans, have been validated to be associated with the acceleration of atherosclerosis in animal models after dietary intervention or intravenous infusion.282930

In the light of these findings, some types of gut bacteria have been identified as novel contributors to the progression of atherosclerosis, while others can protect against atherosclerotic plaque lesions. It is still unknown how the microbes that reside within our bodies can drive or initiate the development of atherosclerosis. It is unclear which species play a leading role in contributing to CVD and the detailed mechanisms involved require further investigation.

One microbial metabolite, trimethylamine N‐oxide (TMAO), has gained considerable attention as a major influencing factor in CVD. The composition of the gut microbiota is altered when dietary patterns change. Trimethylamine (TMA) is generated by the altered microbiota through metabolizing choline,31 phosphatidylcholine,32 L‐carnitine33 and betaine34 via a range of microbial enzymes, primarily TMA lyases. Then TMA enters the liver through the portal circulation and is oxidized into TMAO by hepatic flavin monooxygenases (FMO3).313536Wang et al fed C57BL/6J mice a choline‐enhanced diet and ApoE−/− mice showed an increased risk of atherosclerosis.31 Furthermore, up‐regulation of some types of macrophage scavenger receptors and atherosclerosis was promoted after supplementing mice with TMAO. The serum TMAO level was also positively correlated with the atherosclerotic plaque area. This may be explained by the role of TMAO in inhibiting reverse cholesterol transport and accumulating macrophage cholesterol by means of inducing cell surface expression of two scavenger receptors (differentiation 36 and scavenger receptor A).313337 As a result, increased foam cell formation accelerates atherosclerosis. Additionally, TMAO can decrease cholesterol clearance from the body via inhibiting bile acid synthesis.3839 However, conversely, one study found that TMAO could reduce cholesterol reabsorption and protect against atherosclerosis formation.40

Recently, a series of clinical trials showed the relationship between gut microbiota and CVD events. A study by Li et al revealed that the TMAO level in acute coronary syndromes was an independent predictor of both short‐term (30 days and 6 months) and long‐term (7‐year) major adverse cardiac events.41 Other studies have also highlighted the participation of TMAO in the development of CVD in a variety of patient cohorts.424344 Collectively, mounting evidence suggests that TMAO is part of an important mechanism by which the intestinal microflora influence CVD.


The gut microbiota consists of four major phyla: Firmicutes, Bacteroidetes, Actinobacteria and Proteobacteria. Firmicutes and Bacteroidetes account for a large part of the intestinal microflora. The ratio of Firmicutes (F) and Bacteroidetes (B) (F/B) is considered a biomarker for gut dysbiosis.45 Yang et al demonstrated that microbial richness, diversity and evenness were decreased not only in spontaneously hypertensive rat models but also in a cohort of patients with high blood pressure.46 Additionally, an increased F/B ratio and decreased numbers of acetate‐ and butyrate‐producing bacteria were observed. In Ang II‐infused rats, minocycline intervention was able to lower the blood pressure and induce changes such as increased gut microbial diversity, decreased F/B ratio and expanded populations of acetate‐ and butyrate‐producing bacteria. This indicates that hypertension is linked to gut dysbiosis and that improving gut microbiota may be a target for future therapies for hypertension. Adnan et al10 found that blood pressure can be altered through exchanging the gut microbiota between spontaneously hypertension/stroke‐prone rats (SHRSP) and Wistar‐Kyoto rats (WKY). Systolic blood pressure and F/B ratio were both increased in WKY rats after gavage with SHRSP microbiota. Conversely, systolic blood pressure was decreased in SHRSP rats after gavage with WKY microbiota, although this was not statistically significant. Similarly, the importance of gut microbiota in hypertension formation is evident from a study showing elevated blood pressure in germ‐free mice after transferring faecal material from hypertensive patients to the mice.47 A recent study demonstrated that there were more opportunistic pathogenic taxa (Klebsiella spp, Streptococcus spp and Parabacteroides merdae) involved in the pathogenesis of hypertension and that these were related to the severity of disease.48 These data suggested the direct and indirect role of gut microbiota in the development of hypertension. A number of experiments have further investigated the causality relationship between gut microbiota and high blood pressure in the recent years.

The mechanisms of hypertension are complex and multifactorial. The gut microbiota is considered a risk factor for a variety of diseases including atherosclerosis,23 obesity,49metabolic syndrome50 and diabetes,51 which are proven to be connected with hypertension. In comparison with other intestinal microflora metabolites, more studies have shown the physiological functions of short chain fatty acids (SCFAs) in blood pressure regulation. Bacteria in the gut produce SCFAs by anaerobic fermentation of dietary fibre. The most common SCFAs are acetate, propionate and butyrate. SCFAs are known to mediate multiple biological effects on the endocrine system, the nervous system, CVD, inflammation and gut homeostasis via binding to their receptors, which include G protein‐coupled receptor 41 (GPR41), G protein‐coupled receptor 43 (GPR43), G protein‐coupled receptor 109A (GPR 109A) and vascular olfactory receptor 78 (Olfr78).5253 Olfr78 is expressed in olfactory neurons, renal afferent arterioles as well as in vascular smooth muscle cells, where it plays a role in blood pressure regulation.545556 Olfr78 was found to elevate renin levels, resulting in increased blood pressure, while GPR41 had an antagonistic effect.55 Pluznick et al treated Olfr78˗/˗ and wild‐type mice with antibiotics for a set time period to determine whether metabolites from the microbiota mediate blood pressure via Olfr78.55 The results showed that blood pressure was increased in Olfr78‐/‐ mice after antibiotic treatment, but no effect was seen in the control mice. This indicated that Olfr78 contributes to the hypertensive effects by means of SCFAs. Pluznick et al indicated that GPR41 and Olfr78 had opposing functions in the modulation of blood pressure after responding to propionate (a type of SCFA).56 In addition, SCFAs have also been shown to induce vasorelaxation,57 while other studies have revealed that GRP41 appears to decrease cAMP levels through Gαi.5859

Thus, blood pressure is closely linked to the diversity, richness and evenness of the microbiome living in the gut and it is affected by the F/B ratio. The hypertensive and hypotensive effects of SCFAs are mediated by binding to Olfr78 and GPR41 respectively. The discovery that drug intervention has an influence on blood pressure modulation by changing the species as well as the metabolites of the gut microbiota may provide new ideas for the treatment of hypertension. Moreover, how the intestinal microflora influences blood pressure deserves further exploration.

Heart failure

Heart failure (HF) encompasses a group of complex clinical syndromes that result in damage to the structure or function of the heart. HF is the end stage of many CVDs. Although pharmacological and non‐pharmacological therapies can delay the progression of HF, the short‐ and long‐term mortality rates remain high.606162 Our understanding of the pathophysiological mechanisms of HF has changed greatly in the recent years. The main concept shift is from haemodynamic changes to neurohumoural‐immune regulation. The role of gut microbiota in inflammatory and immune response has drawn attention to the link between the gut microflora and HF.6364

Pasini et al compared the bacteria and fungi in the faeces of HF patients with those of healthy controls.11 The results showed that patients with chronic heart failure (CHF) were colonized by more pathogenic bacteria than the control patients. CandidaCampylobacter and Shigellaspecies were proven to be positively correlated with the severity of disease. Compared with healthy controls, intestinal permeability (IP) increased for 78.3% of the patients with CHF. The gut was more permeable in patients with moderate and severe CHF than patients with mild CHF. Right atrial pressure was positively correlated with IP. In another animal experiment, the abundance of 10 types of faecal flora was changed in HF guinea pigs with pressure overload.65These data suggest that HF can disrupt the balance of intestinal microflora. This prompted researchers to propose the ‘gut hypothesis’. Decreased cardiac output, leading to low perfusion and gastrointestinal congestion, can induce intestinal ischaemia and/or oedema in patients with HF. As a result, the composition of the gut microbiota, intestinal function, morphology and IP are all altered. Secondary intestinal bacterial translocation and increased levels of circulating endotoxin accelerate the systemic inflammatory response, while the activated inflammatory cytokines contribute to HF.666768

Collectively, changes in the intestinal microflora exist in patients with HF. The aforementioned metabolite TMAO generated by the gut microbiota has a certain significance in HF patients. Two cohort studies, which enrolled hundreds of participants, demonstrated that elevated TMAO levels were predictive of the long‐term mortality risk in patients suffering from not only CHF,69but also acute HF.70 TMAO is likely to provide a basis for risk stratification of HF. Organ et al used transverse aortic constriction surgery to induce HF in C57BL6/J mice and found that in mice fed with either TMAO or choline supplemented diets, worse symptoms and signs of HF were observed compared with mice fed a control diet.66 Additionally, plasma levels of TMAO increased in mice fed with dietary TMAO as well as choline because of conversion of choline to TMA by gut microbes. TMAO could accelerate the development of left ventricular dilation, myocardial fibrosis and ventricular remodelling. In agreement with Organ’s observations, Li et al also demonstrated that TMAO played a role in the development of cardiac hypertrophy and cardiac fibrosis.71 The mechanism of increased circulating TMAO levels in patients with HF remains to be determined. Some other gut‐derived metabolites have also been shown to have an impact on HF. Secondary bile acid, transformed by the gut microbiota, was reported to increase in CHF patients,64 and indoxyl sulfate has been linked with myocardial fibrosis and ventricular remodelling.72

In addition to gut microbiota metabolites mentioned above, p‐cresyl sulfate (PCS) and phenylacetylglutamine (PAG) are involved in CVDs as well.7374 PCS is a component of phenolic end products generated by gut microorganism via metabolizing aromatic amino acids, like tyrosine and phenylalanine, in the intestine.75 PCS levels have been shown to predict cardiovascular events and all‐cause mortality in elderly haemodialysis patients.73 Likewise, PAG is one of the colonic microbial metabolites produced by glutamine conjugation of phenylacetic acid, high levels of which were known as a strong and independent risk factor for CVD and mortality in patients with chronic kidney disease.74

More information: The abstract “A different microbial signature in plaque and gut of patients presenting with ACS: a possible role for coronary instability” will be presented during the session Late Breaking Basic and Translational Science – Acute Coronary Syndromes and Heart failure on Saturday 31 August at 13:50 to 15:00 CEST in room Pristina – Village 3.

Provided by European Society of Cardiology


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