Adults with higher blood levels of TMAO had significantly worse artery function


A compound produced in the gut when we eat red meat damages our arteries and may play a key role in boosting risk of heart disease as we get older, according to new University of Colorado Boulder research.

The study, published this month in the American Heart Association journal Hypertension, also suggests that people may be able to prevent or even reverse such age-related decline via dietary changes and targeted therapies, like novel nutritional supplements.

“Our work shows for the first time that not only is this compound directly impairing artery function, it may also help explain the damage to the cardiovascular system that naturally occurs with age,” said first author Vienna Brunt, a postdoctoral researcher in the Department of Integrative Physiology.

Eat a slab of steak or a plate of scrambled eggs, and your resident gut bacteria get to work immediately to break it down.

As they metabolize the amino acids L-carnitine and choline, they churn out a metabolic byproduct called trimethylamine, which the liver converts to trimethylamine-N-Oxide (TMAO) and sends coursing through your bloodstream.

Previous studies have shown that people with higher blood levels of TMAO are more than twice as likely to have a heart attack or stroke and tend to die earlier.

But to date, scientists haven’t completely understood why.

Drawing on animal and human experiments, Brunt and her team set out to answer three questions: Does TMAO somehow damage our vascular system? If so, how? And could it be one reason why cardiovascular health gets worse – even among people who exercise and don’t smoke – as we get older?

The researchers measured the blood and arterial health of 101 older adults and 22 young adults and found that TMAO levels significantly rise with age.

(This falls in line with a previous study in mice, showing the gut microbiome – or your collection of intestinal bacteria – changes with age, breeding more bacteria that help produce TMAO).

Adults with higher blood levels of TMAO had significantly worse artery function, the new study found, and showed greater signs of oxidative stress, or tissue damage, in the lining of their blood vessels.

When the researchers fed TMAO directly to young mice, their blood vessels swiftly aged.

“Just putting it in their diet made them look like old mice,” said Brunt. She noted that 12-month-old mice (the equivalent of humans about 35 years old) looked more like 27-month-old mice (age 80 in people) after eating TMAO for several months.

A link to cognitive decline?

Preliminary data also show that mice with higher levels of TMAO exhibit decreases in learning and memory, suggesting the compound could also play a role in age-related cognitive decline.

On the flip side, old mice that ate a compound called dimethyl butanol, (found in trace amounts in olive oil, vinegar and red wine) saw their vascular dysfunction reverse. Scientists believe that this compound prevents the production of TMAO.

Brunt notes that everyone – even a young vegan – produces some TMAO. But over time, eating a lot of animal products may take a toll.

“The more red meat you eat, the more you are feeding those bacteria that produce it,” she said.

Senior author Doug Seals, director of the Integrative Physiology of Aging Laboratory, said the study is an important breakthrough because it sheds light on why our arteries erode with age, even in the healthiest people.

“Aging is the single greatest risk factor for cardiovascular disease, primarily as a result of oxidative stress to our arteries,” said Seals. “But what causes oxidative stress to develop in our arteries as we age? That has been the big unkown. This study identifies what could be a very important driver.”

The research team is now further exploring compounds that might block production of TMAO to prevent age-related vascular decline.

For now, consider skipping the steak and grilling up some tofu instead, as a plant-based diet can reduce levels of TMAO too.

Within the last decade, cardiovascular disease (CVD) emerged as the leading cause of death worldwide, encompassing multiple disorders such as atherosclerosis (AS) [1]. AS is featured as a chronic inflammatory disease of vascular stenosis due to vascular inflammatory reaction and lipid peroxidation [2, 3]. Indeed, vascular endothelial inflammatory injury is widely considered the initial stage of AS [4].

Furthermore, there is a growing awareness that the gut microbiota is involved in the occurrence and development of AS [5]. The gut microbiota is the collection of microorganisms that inhabit the gastrointestinal tract producing a diverse ecosystem [6].

The homeostasis of the gut microbiota is critical for maintaining human health [7, 8], while gut dysbiosis contributes to the development of various diseases including AS (Table 1) [5].

Using metagenomic analysis of intestinal flora composition, scientists found that the ratio of Firmicutes to Bacteroidetes in patients with AS is much higher than that in controls [9].

Actinobacteria including the genus Collinsella is found in atherosclerotic plaques. Proteobacteria including the genera Chryseomonas and Helicobacter is higher in AS patients compared to healthy adults [10].

Besides, the lowered abundance of Bifidobacteria and Lactobacillus will promote the development of AS [11]. Additionally, Akkermansia muciniphila has been proven to be beneficial in the pathogenesis of AS [12].

Scientists profiled a cross-disease cohort of 1250 individuals to observe the gut microbiome and finally found several disease-relevant bacterial species [13]. The authors suggested that the restoration of the healthy gut microbiome might reduce the risks of CVD as well as other related diseases. Besides, the altered microbiome is closely related to inflammatory status of these diseases.

Table 1

The most important microbiota that influences AS and TMA production [9–13, 27, 88].

PhylaGenusSpeciesASTMA production
Faecalibacteriumcf. prausnitzii
AS: atherosclerosis; TMA: trimethylamine; √: microbiota that influences the occurrence and development of AS; +: microbiota that participates in the TMA formation in the presence of choline.

The gut microbiota can transform dietary nutriment to molecules, among which trimethylamine N-oxide (TMAO) has gained much attention due to its potential role as a promoter of AS [14]. TMAO is derived from trimethylamine (TMA).

TMA is metabolized by the gut microbiota from choline and L-carnitine; then, it can be transferred into the liver and be oxidized by flavin-containing monooxygenase 3 (FMO3) [15, 16].

The transformation of choline and carnitine to TMAO depends on the balance and diversity of the gut microbiota. Gut dysbiosis can directly lead to high plasma TMAO levels and may result in AS development ultimately [17].

Currently, there are convincing evidences suggesting a direct link between TMAO and the pathogenesis of AS. Moreover, the mechanisms of high TMAO triggering AS have attracted much attention [18–20].

In this review, we have extensively retrospected the publications on the topics of gut microbe-dependent TMAO and AS which were mainly published within the past ten years through PubMed.

We have summarized the current state of knowledge about TMAO and discussed the potential causal relationships between TMAO and the development of AS, especially focusing on the impact of TMAO on endothelial inflammatory injury. Finally, we have analyzed the utility of TMAO-targeted therapeutic strategies for the treatment of AS.

Biosynthesis and Metabolism of TMAO

Chemical Properties of TMAO
TMAO is a quaternary amine compound with the formula (CH3)3NO and the molecular weight of 75.1 Da. It is a colorless, odorless solid soluble in water and is usually in the form of a dihydrate. Chemically, it is obtained from TMA by oxidation reaction. The structural formulas of TMA and TMAO are shown in Figure 1. TMAO has a lot of important physiological and biochemical functions in the stability of protein structure, as well as osmotic regulation, resistance to ionic instability, and resistance to water pressure [21].

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Figure 1
Effects of gut microbiota-dependent trimethylamine N-oxide (TMAO) production on atherosclerosis (AS). The gut microbiota metabolizes dietary choline, L-carnitine, and betaine to form TMA (trimethylamine) and TMAO. TMAO is associated with AS by means of disturbance of bile acid metabolism, inhibition of the RCT, inducement of foam cell formation, activation of platelets, and vascular inflammation. FMO3: flavin-containing monooxygenase 3; Cyp: cytochrome P450; Oatp: organic anion-transporting polypeptide; RCT: reverse transport of cholesterol; BA: bile acids.

Biosynthesis of TMAO
The biosynthesis of TMAO is influenced by the following three factors. The first one is the composition of food precursors. Evidences exist that the mostly potential sources of TMAO are choline and L-carnitine from daily diet [15, 16]. Dietary sources including red meat, fish, poultry, and eggs are rich in choline [22]. Researches show that higher dietary phosphatidylcholine leads to enhanced plasma TMAO concentrations in mice and humans [5, 23].

The second factor that affects the biosynthesis of TMAO is intestinal microbial activity. TMAO is a cometabolite of the gut microbiota and the host. Dietary choline or L-carnitine is metabolized by the gut microbiota into TMA in the intestine [24].

Research data show that germ-free mice cannot produce TMA and antibiotic treatment of standard mice can decrease TMA formation. Moreover, transplantation of choline-converting bacteria to gnotobiotic mice can increase TMA production and lower serum choline concentration [5, 25, 26].

These studies have confirmed the irreplaceable role of the gut microbiota in TMAO biosynthesis. In addition, eight distinct bacterial strains participating in TMA formation have been identified, including Anaerococcus hydrogenalis, Clostridium asparagiforme, Clostridium hathewayi, Clostridium sporogenes, Edwardsiella tarda, Escherichia fergusonii, Proteus penneri, and Providencia rettgeri [27] (Table 1).

The third factor that influences TMAO formation is the oxidation of TMA. TMA is a precursor of TMAO, which is transported to the liver and oxidized by flavin-containing monooxygenases (FMO) (Figure 1).

There are three members in the FMO family capable of oxidizing TMA to TMAO, in which FMO3 exhibits the highest specific activity [28]. FMO3 hepatic knockdown mice have lower circulating TMAO levels compared to the normal group, suggesting that FMO3 plays an important role in TMAO formation [29].

In addition, researchers show that hepatic FMO3 expression and TMAO circulating levels are lower in male mice compared to female mice. The reason for the gender difference is that androgens inhibit the FMO3 expression.

However, the differences are much more modest in humans, because of the varied diet consumed by humans [28]. Besides, FMO3 is modulated by the farnesoid X receptor (FXR), a nuclear receptor activated by bile acid [30].

Metabolism of TMAO
After the biosynthesis in the liver, TMAO can be distributed homogeneously throughout the body [15, 23, 31]. TMAO is a small molecule and is readily filtered by the kidneys [32]. A part of TMAO is reduced to TMA by bacterial TMAO reductase in the human gut [33].

TMA and TMAO are excreted mainly in urine within 24 h, as well as in sweat and exhaled air [20]. Research shows that over 95% of TMAO is eliminated by the kidney in the prototype form [34].

TMAO in Atherosclerosis Development
There are accumulating evidences suggesting an association between TMAO and the risk of developing AS [5, 35]. Below, we discuss this association from the perspectives of human trials, animal experiments, and cell culture.

Table 2

Human trials studying the association between TMAO and AS.

SubjectPopulationAge (years)GenderIndicatorMain findingsDuration (years)References
Positive resultsHealthy African American participants3,92437-59Male (33.4%)CIMT; CAC; abdominal aortic calcium and left ventricular mass(1) In women, higher choline intake was associated with lower left ventricular mass and abdominal aortic calcium score
(2) Betaine intake was associated with greater risk of incident CHD
CVD patients and healthy adultsCases 229 and noncases 75155-80Male (41.9%)5 metabolites in the choline pathwayPlasma metabolites from the choline pathway were associated with an increased risk of CVD in a Mediterranean population4.8[37]
Patients undergoing cardiac evaluation2,59554-71Male (70%)Levels of L-carnitine and TMAO in plasma and urine(1) There was a dose-dependent association between carnitine concentration and risk of CVD
(2) Carnitine concentration predicted an incident (3-year) risk of major adverse cardiac events
(3) TMAO was the primary driver of the association of carnitine with CVD risk
Patients undergoing elective coronary angiography4,00752-74Male (64%)Levels of TMAO in plasma and urine; plasma choline and betaineIncreased plasma concentrations of TMAO were associated with increased risks of major adverse cardiovascular events3[23]
Patients undergoing cardiovascular surgery22761–74Male (70%)Levels of TMAO in serum; number of infarcted coronary arteriesHigher serum TMAO levels were associated with an increased number of infarcted coronary arteries[38]
Patients with stable coronary artery disease2,23552-74Male (71%)Levels of TMAO in plasmaElevated concentrations of plasma TMAO were associated with incident mortality and artery infarction, independent of other traditional risk factors in stable cardiac patients5[39]
Urban Chinese adults in a nested case-control study275 patients with CHD and 275 controls62.2 ± 8.7Male (46%)Urinary levels of TMAOUrinary TMAO was correlated with the risk of CHD10[40]
Multiethnic participants27142-63Male (64.9%)Levels of TMAO in serumAn association of TMAO with prevalent CVD in a multiethnic population[89]
Negative resultsHealthy participants81733-55Male (52%)Levels of TMAO in plasma; CIMT; CACTMAO may not contribute significantly to advancing early AS risk among healthy early-middle-aged adults10[41]
Patients of suspected CAD33955-71Male (68%)Plasma TMAO or betaine levelsPlasma levels of TMAO were not associated with the history, presence, or incidence of CVD events8[42]
Patients with large-artery atherosclerotic ischemic stroke and TIA322 patients and 231 controls56-61Male (63.2%)Plasma TMAO(1) There was no obvious change of blood TMAO levels in asymptomatic AS
(2) TMAO levels were decreased in stroke and TIA patients
AS: atherosclerosis; CVD: cardiovascular disease; TMAO: trimethylamine N-oxide; CAC: coronary artery calcium; CIMT: carotid intima-media thickness; CHD: coronary heart disease; TIA: transient ischemic attack; CAD: coronary artery disease.

Higher dietary betaine intake was associated with a nonlinear higher risk of incident coronary heart disease in 3,924 African Americans [36].

A follow-up study included 229 CVD patients and 751 randomly selected healthy participants in a Mediterranean population. The results of this study indicated that plasma concentrations of five metabolites in the choline pathway were associated with increased risks of major adverse cardiovascular events [37].

In patients (n = 2,595) undergoing cardiac evaluation, choline and L-carnitine in plasma predicted increased risks of major adverse cardiac events [25]. In the clinical outcome study of 4,007 participants, increased plasma concentrations of TMAO were associated with enhanced risks of major adverse cardiovascular events during the 3-year follow-up [23].

In a cross-sectional study of 227 patients, higher serum TMAO levels may be associated with an increased number of infarcted coronary arteries in patients who undergo cardiovascular surgery [38]. Additionally, in a 5-year follow-up study, patients with stable coronary artery disease participated in the experiment.

The results showed that elevated plasma TMAO levels were associated with incident mortality and artery infarction [39]. Another report indicated that urinary TMAO was correlated with the risks of coronary heart diseases (n = 275) [40].

However, there are still some opposite results about the correlation between TMAO and AS. The plasma levels of TMAO in humans correlate positively with an increase in age. In a cohort of subjects (n = 817) of ages 35-55 over a 10-year follow-up, there was no significant association between TMAO concentrations and AS progression [41].

This study was conducted in relatively younger and healthier individuals as compared to other studies. Based on this result, we speculate that because these early-middle-age patients were mostly in the early stages of AS progression, the cardiovascular effects of TMAO have not yet emerged. Besides, TMAO is excreted in urine.

Kidney function in younger individuals is better than that in older ones; therefore, TMAO can be cleared out of the body in time. These results indicate that the conclusion of high TMAO correlating with AS is persuasive after excluding age-related factors.

Besides, it is reported that TMAO levels in plasma are confounded by impaired kidney function and poor metabolic control but are not associated with the presence of coronary heart disease [42]. In addition, researches performed a case-control study of patients with large-artery atherosclerotic ischemic stroke and TIA (transient ischemic attack) [43].

There was no obvious change of blood TMAO levels in asymptomatic AS, which is in the early stages of AS progression. Besides, the TMAO levels decreased in stroke and TIA patients compared to controls. As the authors postulated, it was the stroke event and the treatment that reduced TMAO levels.

Another report also indicated no remarkable association between TMAO and carotid AS [44]. There were some limitations in this analysis including the use of nonfasting samples, lack of information of vegetarians versus omnivores, incomplete consideration about patient inclusion, and the small event rate.

To summarize this part, differences in the study designs, clinical contexts, geographic and ethnic backgrounds, or dietary habits may alter the role of TMAO in AS progression. Therefore, in the further human trials, demographics, genetic factors, medication, disease staging, dietary habits, and food intake of the participants should be taken into consideration.

TMAO Induces Endothelial Inflammatory Injury
AS is considered a chronic inflammatory disease initiated by vascular endothelial inflammatory injury [2, 3]. In recent years, TMAO is identified as a predictor of AS using a metabolomics approach in the clinical studies as we discussed above.

Moreover, TMAO is shown to have an impact on endothelial inflammatory injury in both in vivo studies and in vitro studies [31, 54] (Table 4).

able 4

Researches about TMAO inducing endothelial inflammatory injury.

Experimental modelsResultsProposed mechanismsReferences
Positive resultsCAECsTMAO induced IL-1β production↑ NLRP3 inflammasomes
↑ Endothelial hyperpermeability
HUVECs/ApoE−/− miceTMAO promoted the release of IL-1β↓ SIRT3-SOD2-mitochondrial ROS signaling pathway
↑ NLRP3 inflammasome
FHCsTMAO contributed to colonic epithelial inflammation and promoted the release of inflammatory cytokines↓ ATG16L1-induced autophagy
↑ NLRP3 inflammasome
LDLR−/− mice/HAECs/HVSMCsTMAO promoted the release of inflammatory cytokines and promoted the recruitment of activated leukocytes to endothelial cells↑ MAPK and NF-κB signaling pathway[54]
THP-1/HUVECsTMAO decreased endothelial self-repair and increased monocyte adhesion↑ PKC/NF-κB/VCAM-1 pathway[52]
HUVECsTMAO augmented the release of IL-1β and IL-18 and triggered oxidative stress↑ TXNIP-NLRP3 inflammasome[56]
RatsTMAO increased the release of TNF-α and IL-1β and promoted oxidative stress↓ eNOS-derived NO production in the aorta[55]
Human/SAMR1 mice/SAMP8 mice/HUVECsTMAO increased oxidative stress both in vivo and in vitro↓ SIRT1 expression
↑ p53/p21/Rb pathway
HUVECsTMAO enhanced the protein expression of p65, p-p65, lamin A, lamin C, ERK, p-ERK, p38, p-p38, and COX-2; TMAO induced the proliferation and apoptosis of HUVECs↑ NF-κB/MAPK pathways[64]
Negative results31 HD patients with carnitine deficiencyOral L-carnitine supplementation was associated with increased TMAO levels, whereas it decreased ICAM-1, VCAM-1, and MDA levelsLimitations: age, gender, and lifestyles of the participants were not taken into account, especially medication interference[65]
271 healthy adults, ≥18 years oldAugmented TMAO levels in plasma led to an overexpression of TNF-α and two soluble TNF receptors but were not related to CRP or IL-6Limitations: the long-term dietary habits differed among the participants and the food intake was hard to assess[19]
20 healthy aged womenNo relation between TMAO and any oxidative stress markersLimitations: the number of participants was small[66]
TMAO: trimethylamine N-oxide; TNF-α: tumor necrosis factor-α; IL-1β: interleukin 1β; IL-10: interleukin 10; CAECs: carotid artery endothelial cells; NLRP3: the nod-like receptor family pyrin domain containing 3; HUVECs: human umbilical vein endothelial cells; ApoE−/−: apolipoprotein E-deficient; SIRT3: sirtuin 3; SOD2: superoxide dismutase 2; ROS: reactive oxygen species; FHCs: fetal human colon cells; ATG16L1: autophagy-related protein; LDLR−/−: lipoprotein receptor-deficient; HAECs: human umbilical artery endothelial cells; HVSMCs: human vascular smooth muscle cells; PKC: protein kinase C; NF-κB: nuclear factor-κB; VCAM-1: vascular cell adhesion molecule-1; eNOS: endothelial nitric oxide synthase; NO: nitric oxide; TXNIP: thioredoxin-interacting protein; SAMR1 mice: senescence-accelerated mouse resistance 1; SAMP8 mice: senescence-accelerated mouse prone 8; HD: hemodialysis; ICAM-1: intercellular cell adhesion molecule-1; MDA: malondialdehyde; ERK: extracellular signal-regulated kinase; COX: cyclooxygenase.

TMAO Promotes the Release of Inflammatory Cytokines
TMAO treatment induces the release of inflammatory cytokines, contributing to the development of AS. Researches verified that the process of aging increased circulating TMAO levels, which may increase the expression of tumor necrosis factor-α (TNF-α), IL-1β, and IL-10 [18, 55].

In human umbilical vein endothelial cells (HUVECs), TMAO enhanced the levels of IL-1β and IL-18 in a dose-and time-dependent manner [56]. In carotid artery endothelial cells (CAECs), TMAO activated the nod-like receptor family pyrin domain containing 3 (NLRP3) inflammasomes, thereby inducing endothelial hyperpermeability and promoting the release of inflammatory cytokines [57].

Additionally, in LDLR−/− mice, acute TMAO injection led to the upregulated inflammatory markers and the activated inflammatory pathways, including MAPK and NF-κB signaling pathways. These observations were recapitulated in human aortic endothelial cells (HAECs) and vascular smooth muscle cells (VSMCs) [54].

TMAO Enhances Inflammation Adhesion
Results demonstrated that TMAO induced the pathological process of AS by accelerating endothelial dysfunction, including increasing monocyte adhesion. Studies verified that TMAO promoted the recruitment of activated leukocytes to endothelial cells via the activation of MAPK and NF-κB signaling pathways [54].

In addition, TMAO could upregulate the expression of vascular cell adhesion molecule-1 (VCAM-1) though the activation of the PKC/NF-κB pathway, which ultimately increased monocyte adhesion [52].

TMAO Promotes Oxidative Stress
Several studies showed that high plasma TMAO could cause endothelial dysfunction and vascular inflammation due to promoting oxidative stress [55, 56, 58, 59]. TMAO significantly triggered oxidative stress by inhibiting the activity of endothelial nitric oxide synthase (eNOS) and production of nitric oxide (NO) via the activation of the TXNIP-NLRP3 inflammasome [56]. Studies about age-related CVD also verified that TMAO triggered oxidative stress.

Circulating TMAO levels were elevated with age, which may increase vascular inflammation and oxidative stress by impairing eNOS-derived NO bioavailability [55]. Elevated circulating TMAO during the aging process may increase oxidative stress because of repression of SIRT1 expression and activation of the p53/p21/Rb pathway [59].

The Mechanisms of TMAO Promoting Endothelial Inflammatory Injury
In conclusion of the studies above, we have summarized the mechanisms of TMAO promoting endothelial inflammatory injury as follows (Figure 2).

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Figure 2
The mechanisms of TMAO (trimethylamine N-oxide) inducing endothelial inflammatory injury. TMAO can promote the release of inflammatory cytokines, enhance the monocyte adhesion to the endothelial cells, and promote the oxidative stress. IL-1β: interleukin 1β; IL-18: interleukin 18; NLRP3: the nod-like receptor family pyrin domain containing 3; SIRT3: sirtuin 3; SOD2: superoxide dismutase 2; mtROS: mitochondrial reactive oxygen species; ROS: reactive oxygen species; PKC: protein kinase C; NF-κB: nuclear factor-κB; NO: nitric oxide; TRX: thioredoxin; ASC: apoptosis-associated speck-like protein; caspase-1: cysteinyl aspartate-specific proteinase-1; TXNIP: thioredoxin-interacting protein; MAPK: mitogen-activated protein kinase.

The first approach is TMAO-mediated mtROS production and activation of the NLRP3 inflammasomes. After the biosynthesis in the liver, TMAO goes into the blood vessels and inhibits sirtuin 3 (SIRT3). Sirtuins are NAD+-dependent enzymes. SIRT3 directly binds to and deacetylates SOD2. Thereby, inhibition of SIRT3 decreases SOD2 activity and then leads to a significantly bad effect on mtROS homeostasis [60, 61].

Subsequently, elevated ROS production leads to inhibition of NO release, thus contributing to oxidative stress [55]. Besides, elevated ROS production induces the dissociation of thioredoxin-interactive protein (TXNIP) from thioredoxin (TRX). As a consequence, TXNIP activates the NLRP3 inflammasome, thus upregulating IL-1β and IL-18 [56, 62].

The second approach is activation of the NF-κB signaling pathway by TMAO. TMAO activates protein kinase C (PKC) and consequently contributes to the activation of the NF-κB pathway [52]. After the activation of PKC, IκB is degraded by phosphorylation and the trimer is disintegrated to release the activated NF-κB [63]. Due to the activation of the NF-κB pathway, a cascade of cellular inflammatory responses occurs, including the release of inflammatory cytokines and monocyte adhesion with the vascular endothelium.

And last but not least, TMAO inhibits the activity of MAPK/ERK, reduces the activation of the NF-κB pathway, and consequently decreases the inflammatory response [54, 64].

However, there are some studies providing an opposite result. In a cohort of 31 patients who underwent hemodialysis, high plasma TMAO levels induced by oral L-carnitine supplementation could decrease markers of vascular injury and oxidative stress such as ICAM-1, VCAM-1, and malondialdehyde (MDA) levels [65]. Some limitations in this article were responsible for these results.

Age and gender were not taken into account in this article. This study did not change the participants’ lifestyles; thus, it could not totally exclude the medication interference. Besides, this study has small sample size with high dropout rates. Another study providing an opposite result was conducted among 271 healthy adults. This study suggested that TMAO concentrations were not related to C-reactive protein (CRP) or IL-6 concentrations, but with TNF-α, and two soluble TNF receptors [19].

The reason for the opposite result may be that the long-term dietary habits differed among the participants and the food intake was hard to assess. The third opposite results indicated no relation between TMAO and any oxidative stress markers [66]. This conclusion was based on 20 healthy aged women. The authors should increase the number of participants for eliminating distractions.

To better explore the mechanisms that TMAO develops AS and induces endothelial inflammatory injury, researchers should pay more attention to details about experimental setups, such as strains, genders, diet, and housing conditions of laboratory animals. However, in consideration of the difference between the mouse model and humans, more researches and data of human trials should be provided to support these mechanisms. Besides, human trials need to follow the recommendations we made in the previous section.

Therapeutic Strategies
According to the discussion above, TMAO is a metabolite produced by the gut microbiota and is one of the causes of AS. This link between TMAO and AS provides an opportunity to identify new therapeutic targets to ameliorate vascular inflammation and cure the diseases. Several therapeutic strategies of decreasing TMAO levels are summarized in Table 5 [67].

Table 5

Therapeutic strategies targeting the reduction of TMAO generation.

Targeting the gut microbiotaPrebioticsGut microbiota composition was improved, thus decreasing TMAO formationGut microbiota composition was affected by a variety of factors[68]
Probiotics(1) The use of Lactobacillus paracasei reduced TMA production in mice expressing the human baby microbiota
(2) Methanogenic bacteria depleted TMAO
(3) Lactobacillus and Bifidobacterium genera are used as probiotics to reduce the extent of AS
The effects were not clear in humans[6971]
Antibiotics(1) Mixed antibiotics in mice led to an inhibition of plasma TMAO levels and inhibition of macrophage foam cell formation
(2) The use of oral broad-spectrum antibiotics suppressed TMAO levels in a human trial
Bacterial resistance and inhibition of the beneficial bacteria[523]
Targeting TMA formationDMBTMA lyase was inhibited, resulting in TMAO formation decreaseStudies performed in mice and rats, not in humans
DMB cannot avoid the complete TMAO synthesis
MeldoniumExcretion of TMAO was increased though urine; TMAO biosynthesis from L-carnitine was reducedTMAO formation from choline cannot be reduced[7677]
CutC/D inhibitorsCutC and cntA amplicons were related to the TMA-forming-related gut microbiotaThe experimental results need further investigation[78]
PSEsPSEs attenuated cholesterol accumulation and prevented AS by inhibiting microbial production of TMA in ApoE−/− miceStudies have been performed in mice only[79]
FMO3 enzyme inhibitorTransformation of TMAO from TMA was inhibitedTMA is accumulated in plasma and causes some new diseases[3080]
Herbal productsGynostemma pentaphyllumPlasma TMAO levels were reduced in ratsStudies have been performed in rats only[81]
Concomitant use of Gancao and FuziPlasma TMAO levels were reduced in ratsStudies have been performed in rats only[82]
ResveratrolGut microbiota composition was modulated, thus decreasing TMA-forming bacteria and increasing the beneficial bacteriaStudies have been performed in mice only[83]
Oolong tea extract and citrus peel polymethoxyflavonesThe gut microbiota was remodeled; then, TMAO formation and vascular inflammation were reducedStudies have been performed in mice only[84]
BBRBBR could change the abundances of Firmicutes and Verrucomicrobia and reduce the expression of hepatic FMO3 and serum TMAO levels markedlyStudies have been performed in mice only[85]
TrigonellineTrigonelline inhibited the formation of TMAO from TMA by inhibiting FMO3Studies have been performed in mice only[86]
TMAO: trimethylamine N-oxide; TMA: trimethylamine; DMB: 3,3-dimethyl-1-butanol; cutC: choline TMA lyase; cntA: carnitine oxygenase; PSEs: plant sterol esters; FMO3: flavin-dependent monooxygenase 3; BBR: berberine.

Therapies Targeting the Gut Microbiota to Reduce TMAO Generation
The use of prebiotics and probiotics could be helpful to elicit a positive impact on gut microbiota composition, resulting in the regulation of TMAO generation [68]. Prebiotics are nondigestible food components that have beneficial effects on the host by selectively stimulating the growth and activity of beneficial bacteria, while probiotics are living microbes capable of producing beneficial effects on human health.

Mice colonized with human infant flora had a reduced TMA production [69]. Other studies have initiated the use of archaea to deplete TMA and TMAO, because these archaea use methyl compounds such as TMA and TMAO as the substrate to generate methane [70, 71]. Lactobacillus and Bifidobacterium genera are used as probiotics to reduce the extent of AS and bring comprehensive benefits to life [72].

Recently, it is reported that probiotics significantly promoted the anti-inflammatory cytokine IL-10 and decreased proinflammatory cytokines such as IL-1β [73]. The mechanisms that probiotics prevent AS can be concluded as modulation of the gut microbiome and regulation of miRNA [74].

Considering the gut microbiota which is responsible for the synthesis of TMAO, we can find and utilize some probiotic strains to prevent AS. The weakness of this strategy is that the treatment effects vary from person to person, because gut microbiota composition is affected by a variety of factors.

The use of antibiotics to eliminate the microbiota has also been devised in treating CVD. Antibiotics can prevent dietary precursors (choline, betaine, and L-carnitine) being transformed into TMA. The use of oral broad-spectrum antibiotics such as ciprofloxacin and metronidazole suppressed TMAO levels in a human trial [23].

However, the levels of TMAO were detectable one month after taking the antibiotics. A mix use of vancomycin, neomycin-sulphate, metronidazole, and ampicillin in mice unveiled an inhibition of plasma TMAO levels and inhibition of macrophage foam cell formation [5]. However, the chronic application of antibiotics is not viable since it can lead to bacterial resistance and inhibition of the beneficial bacteria. Thus, additional researches are needed to ensure the safety of antibiotics.

Therapies Targeting TMA to Reduce TMAO Generation
Another appealing approach is the inhibition of TMA biosynthesis. 3,3-Dimethyl-1-butanol (DMB), an analogue of choline that inhibits choline TMA lyase, can reduce plasma TMAO levels and attenuate the development of choline diet-enhanced AS [18, 75]. However, DMB is not able to avoid the TMAO synthesis completely.

Another report proposed the use of meldonium, a compound used as an anti-ischemic and antiatherosclerotic drug [76]. It seemed to reduce plasma TMA levels in humans by increasing its urinary excretion and reducing its biosynthesis from L-carnitine [77]. However, meldonium reduces TMA formation from L-carnitine, but not from choline. Another study examined the TMA-forming-related gut microbiota and found that choline TMA lyase (cutC) and carnitine oxygenase (cntA) amplicons were related to various taxa [78].

However, these experimental results need further investigation before clinical application. In addition, plant sterol esters (PSEs) were also identified to attenuate cholesterol accumulation and prevent AS by inhibiting microbial production of TMA in ApoE−/− mice [79].

There is another option, FMO3 enzyme inhibitor, which is able to cut down the transformation of TMA into TMAO. Hepatic knockdown of FMO3 in mice using an antisense oligonucleotide decreased circulating TMAO levels and attenuated AS [30, 80]. But this treatment is hard to replicate in humans, because FMO3 is involved in the oxidative metabolism of a large number of drugs, exogenous substances, and other chemicals in the body, not just TMAO. Another problem would be that after hepatic knockdown of FMO3, TMA will be accumulated in plasma resulting in trimethylaminuria and causing some new diseases.

Herbal Products Reducing TMAO Generation
Several herbal products reveal an impact on decreasing plasma TMAO levels. Gynostemma pentaphyllum, a plant used as a traditional Chinese medicine to treat hyperlipidemia and obesity, seemed to reduce plasma TMAO levels in rats [81]. Besides, Gancao, the root of Glycyrrhiza uralensis, seemed to reduce TMAO levels when Fuzi (the processed lateral root of Aconitum carmichaelii) was coadministered [82].

Some researches proposed resveratrol, a natural polyphenolic compound in the diet, which could modulate gut composition, decreasing TMA-forming bacteria and increasing the beneficial bacteria [83]. Oolong tea extract and citrus peel polymethoxyflavones could reduce TMAO production in L-carnitine-feeding mice [84].

Berberine (BBR) is used for antigastrointestinal tract infection clinically. In male ApoE−/− mice fed with high-fat diet, BBR could change the abundances of Firmicutes and Verrucomicrobia and reduce the expression of hepatic FMO3 and serum TMAO levels markedly [85]. Another natural pharmaceutical ingredient, trigonelline, a compound from Trigonella foenum-graecum, inhibited the formation of TMAO from TMA by inhibiting FMO3 [86]. However, the effects of herbal products are mostly verified in mice, not in humans.

In conclusion, the therapeutic strategies mentioned above have certain limitations or shortcomings. In the future, new therapeutic targets based on the role of TMAO in vascular inflammation could lead to a promising therapeutic avenue in the treatment of AS. Herbal products are a treasure with multicomponent and multitarget, from which we can dig out new therapeutic strategies reducing TMAO generation.


More information: Vienna E. Brunt et al. Trimethylamine-N-Oxide Promotes Age-Related Vascular Oxidative Stress and Endothelial Dysfunction in Mice and Healthy Humans, Hypertension (2020). DOI: 10.1161/HYPERTENSIONAHA.120.14759


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