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Koeth RA, Smith JD, Chung MK. Artificial Sweeteners: A New Dietary Environmental Risk Factor for Atrial Fibrillation? Circ Arrhythm Electrophysiol 2024; 17:e012761. [PMID: 38440869 PMCID: PMC10958529 DOI: 10.1161/circep.124.012761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Affiliation(s)
- Robert A Koeth
- Department of Cardiovascular and Metabolic Sciences (R.A.K., J.D.S., M.K.C.), Lerner Research Institute, Cleveland, OH
- Center for Microbiome and Human Health (R.A.K.), Lerner Research Institute, Cleveland, OH
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH (R.A.K., M.K.C.)
| | - Jonathan D Smith
- Department of Cardiovascular and Metabolic Sciences (R.A.K., J.D.S., M.K.C.), Lerner Research Institute, Cleveland, OH
| | - Mina K Chung
- Department of Cardiovascular and Metabolic Sciences (R.A.K., J.D.S., M.K.C.), Lerner Research Institute, Cleveland, OH
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH (R.A.K., M.K.C.)
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2
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Tang WHW, Nemet I, Li XS, Wu Y, Haghikia A, Witkowski M, Koeth RA, Demuth I, König M, Steinhagen-Thiessen E, Bäckhed F, Fischbach MA, Deb A, Landmesser U, Hazen SL. Prognostic value of gut microbe-generated metabolite phenylacetylglutamine in patients with heart failure. Eur J Heart Fail 2024; 26:233-241. [PMID: 38124458 DOI: 10.1002/ejhf.3111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 12/23/2023] Open
Abstract
AIM Phenylacetylglutamine (PAGln) is a phenylalanine-derived metabolite produced by gut microbiota with mechanistic links to heart failure (HF)-relevant phenotypes. We sought to investigate the prognostic value of PAGln in patients with stable HF. METHODS AND RESULTS Fasting plasma PAGln levels were measured by stable-isotope-dilution liquid chromatography-tandem mass spectrometry (LC-MS/MS) in patients with stable HF from two large cohorts. All-cause mortality was assessed at 5-year follow-up in the Cleveland cohort, and HF, hospitalization, or mortality were assessed at 3-year follow-up in the Berlin cohort. Within the Cleveland cohort, median PAGln levels were 4.2 (interquartile range [IQR] 2.4-6.9) μM. Highest quartile of PAGln was associated with 3.09-fold increased mortality risk compared to lowest quartile. Following adjustments for traditional risk factors, as well as race, estimated glomerular filtration rate, amino-terminal pro-B-type natriuretic peptide, high-sensitivity C-reactive protein, left ventricular ejection fraction, ischaemic aetiology, and HF drug treatment, elevated PAGln levels remained predictive of 5-year mortality in quartile comparisons (adjusted hazard ratio [HR] [95% confidence interval, CI] for Q4 vs Q1: 1.64 [1.07-2.53]). In the Berlin cohort, a similar distribution of PAGln levels was observed (median 3.2 [IQR 2.0-4.8] μM), and PAGln levels were associated with a 1.92-fold increase in 3-year HF hospitalization or all-cause mortality risk (adjusted HR [95% CI] for Q4 vs Q1: 1.92 [1.02-3.61]). Prognostic value of PAGln appears to be independent of trimethylamine N-oxide levels. CONCLUSION High levels of PAGln are associated with adverse outcomes independent of traditional cardiac risk factors and cardio-renal risk markers.
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Affiliation(s)
- W H Wilson Tang
- Center for Microbiome and Human Health, Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ina Nemet
- Center for Microbiome and Human Health, Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xinmin S Li
- Center for Microbiome and Human Health, Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Yuping Wu
- Department of Mathematics and Statistics, Cleveland State University, Cleveland, OH, USA
| | - Arash Haghikia
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Marco Witkowski
- Center for Microbiome and Human Health, Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Robert A Koeth
- Center for Microbiome and Human Health, Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ilja Demuth
- Department of Endocrinology and Metabolism, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
| | - Maximilian König
- Berlin Institute of Health (BIH), Berlin, Germany
- Department of Endocrinology and Metabolism, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Fredrik Bäckhed
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine and Sahlgrenska Center for Cardiovascular and Metabolic Research, University of Gothenburg, Gothenburg, Sweden
- Novo Nordisk Foundation Center for Basic Metabolic Research Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Physiology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Michael A Fischbach
- Department of Bioengineering and ChEM-H, Stanford University, Stanford, CA, USA
| | - Arjun Deb
- Division of Cardiology and Department of Medicine, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Ulf Landmesser
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Stanley L Hazen
- Center for Microbiome and Human Health, Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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3
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Wang Z, Bergeron N, Levison BS, Li XS, Chiu S, Jia X, Koeth RA, Li L, Wu Y, Tang WHW, Krauss RM, Hazen SL. Impact of chronic dietary red meat, white meat, or non-meat protein on trimethylamine N-oxide metabolism and renal excretion in healthy men and women. Eur Heart J 2019; 40:583-594. [PMID: 30535398 PMCID: PMC6374688 DOI: 10.1093/eurheartj/ehy799] [Citation(s) in RCA: 255] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 08/21/2018] [Accepted: 11/19/2018] [Indexed: 01/06/2023] Open
Abstract
AIMS Carnitine and choline are major nutrient precursors for gut microbiota-dependent generation of the atherogenic metabolite, trimethylamine N-oxide (TMAO). We performed randomized-controlled dietary intervention studies to explore the impact of chronic dietary patterns on TMAO levels, metabolism and renal excretion. METHODS AND RESULTS Volunteers (N = 113) were enrolled in a randomized 2-arm (high- or low-saturated fat) crossover design study. Within each arm, three 4-week isocaloric diets (with washout period between each) were evaluated (all meals prepared in metabolic kitchen with 25% calories from protein) to examine the effects of red meat, white meat, or non-meat protein on TMAO metabolism. Trimethylamine N-oxide and other trimethylamine (TMA) related metabolites were quantified at the end of each diet period. A random subset (N = 13) of subjects also participated in heavy isotope tracer studies. Chronic red meat, but not white meat or non-meat ingestion, increased plasma and urine TMAO (each >two-fold; P < 0.0001). Red meat ingestion also significantly reduced fractional renal excretion of TMAO (P < 0.05), but conversely, increased fractional renal excretion of carnitine, and two alternative gut microbiota-generated metabolites of carnitine, γ-butyrobetaine, and crotonobetaine (P < 0.05). Oral isotope challenge revealed red meat or white meat (vs. non-meat) increased TMA and TMAO production from carnitine (P < 0.05 each) but not choline. Dietary-saturated fat failed to impact TMAO or its metabolites. CONCLUSION Chronic dietary red meat increases systemic TMAO levels through: (i) enhanced dietary precursors; (ii) increased microbial TMA/TMAO production from carnitine, but not choline; and (iii) reduced renal TMAO excretion. Discontinuation of dietary red meat reduces plasma TMAO within 4 weeks.
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Affiliation(s)
- Zeneng Wang
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH, USA
| | - Nathalie Bergeron
- Department of Atherosclerosis Research, Children’s Hospital Oakland Research Institute, Martin Luther King Jr Way, Oakland, CA, USA
- Department of Biological and Pharmaceutical Sciences, College of Pharmacy, Touro University California, Club Drive, Mare Island, Vallejo, CA, USA
| | - Bruce S Levison
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH, USA
| | - Xinmin S Li
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH, USA
| | - Sally Chiu
- Department of Atherosclerosis Research, Children’s Hospital Oakland Research Institute, Martin Luther King Jr Way, Oakland, CA, USA
| | - Xun Jia
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH, USA
| | - Robert A Koeth
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH, USA
| | - Lin Li
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH, USA
| | - Yuping Wu
- Department of Mathematics, Cleveland State University, Euclid Ave, Cleveland, OH, USA
| | - W H Wilson Tang
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH, USA
| | - Ronald M Krauss
- Department of Atherosclerosis Research, Children’s Hospital Oakland Research Institute, Martin Luther King Jr Way, Oakland, CA, USA
| | - Stanley L Hazen
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH, USA
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4
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Koeth RA, Lam-Galvez BR, Kirsop J, Wang Z, Levison BS, Gu X, Copeland MF, Bartlett D, Cody DB, Dai HJ, Culley MK, Li XS, Fu X, Wu Y, Li L, DiDonato JA, Tang WHW, Garcia-Garcia JC, Hazen SL. l-Carnitine in omnivorous diets induces an atherogenic gut microbial pathway in humans. J Clin Invest 2018; 129:373-387. [PMID: 30530985 DOI: 10.1172/jci94601] [Citation(s) in RCA: 189] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 10/30/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND l-Carnitine, an abundant nutrient in red meat, accelerates atherosclerosis in mice via gut microbiota-dependent formation of trimethylamine (TMA) and trimethylamine N-oxide (TMAO) via a multistep pathway involving an atherogenic intermediate, γ-butyrobetaine (γBB). The contribution of γBB in gut microbiota-dependent l-carnitine metabolism in humans is unknown. METHODS Omnivores and vegans/vegetarians ingested deuterium-labeled l-carnitine (d3-l-carnitine) or γBB (d9-γBB), and both plasma metabolites and fecal polymicrobial transformations were examined at baseline, following oral antibiotics, or following chronic (≥2 months) l-carnitine supplementation. Human fecal commensals capable of performing each step of the l-carnitine→γBB→TMA transformation were identified. RESULTS Studies with oral d3-l-carnitine or d9-γBB before versus after antibiotic exposure revealed gut microbiota contribution to the initial 2 steps in a metaorganismal l-carnitine→γBB→TMA→TMAO pathway in subjects. Moreover, a striking increase in d3-TMAO generation was observed in omnivores over vegans/vegetarians (>20-fold; P = 0.001) following oral d3-l-carnitine ingestion, whereas fasting endogenous plasma l-carnitine and γBB levels were similar in vegans/vegetarians (n = 32) versus omnivores (n = 40). Fecal metabolic transformation studies, and oral isotope tracer studies before versus after chronic l-carnitine supplementation, revealed that omnivores and vegans/vegetarians alike rapidly converted carnitine to γBB, whereas the second gut microbial transformation, γBB→TMA, was diet inducible (l-carnitine, omnivorous). Extensive anaerobic subculturing of human feces identified no single commensal capable of l-carnitine→TMA transformation, multiple community members that converted l-carnitine to γBB, and only 1 Clostridiales bacterium, Emergencia timonensis, that converted γBB to TMA. In coculture, E. timonensis promoted the complete l-carnitine→TMA transformation. CONCLUSION In humans, dietary l-carnitine is converted into the atherosclerosis- and thrombosis-promoting metabolite TMAO via 2 sequential gut microbiota-dependent transformations: (a) initial rapid generation of the atherogenic intermediate γBB, followed by (b) transformation into TMA via low-abundance microbiota in omnivores, and to a markedly lower extent, in vegans/vegetarians. Gut microbiota γBB→TMA/TMAO transformation is induced by omnivorous dietary patterns and chronic l-carnitine exposure. TRIAL REGISTRATION ClinicalTrials.gov NCT01731236. FUNDING NIH and Office of Dietary Supplements grants HL103866, HL126827, and DK106000, and the Leducq Foundation.
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Affiliation(s)
- Robert A Koeth
- Department of Cellular and Molecular Medicine, Lerner Research Institute.,Center for Microbiome and Human Health, and.,Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Jennifer Kirsop
- Department of Cellular and Molecular Medicine, Lerner Research Institute.,Center for Microbiome and Human Health, and
| | - Zeneng Wang
- Department of Cellular and Molecular Medicine, Lerner Research Institute.,Center for Microbiome and Human Health, and
| | - Bruce S Levison
- Department of Cellular and Molecular Medicine, Lerner Research Institute
| | - Xiaodong Gu
- Department of Cellular and Molecular Medicine, Lerner Research Institute.,Center for Microbiome and Human Health, and
| | | | - David Bartlett
- Department of Cellular and Molecular Medicine, Lerner Research Institute
| | | | - Hong J Dai
- Global Biosciences, The Procter & Gamble Company, Cincinnati, Ohio, USA
| | - Miranda K Culley
- Department of Cellular and Molecular Medicine, Lerner Research Institute
| | - Xinmin S Li
- Department of Cellular and Molecular Medicine, Lerner Research Institute.,Center for Microbiome and Human Health, and
| | - Xiaoming Fu
- Department of Cellular and Molecular Medicine, Lerner Research Institute.,Center for Microbiome and Human Health, and
| | - Yuping Wu
- Department of Mathematics, Cleveland State University, Cleveland, Ohio, USA
| | - Lin Li
- Department of Cellular and Molecular Medicine, Lerner Research Institute.,Center for Microbiome and Human Health, and
| | - Joseph A DiDonato
- Department of Cellular and Molecular Medicine, Lerner Research Institute.,Center for Microbiome and Human Health, and
| | - W H Wilson Tang
- Department of Cellular and Molecular Medicine, Lerner Research Institute.,Center for Microbiome and Human Health, and.,Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Stanley L Hazen
- Department of Cellular and Molecular Medicine, Lerner Research Institute.,Center for Microbiome and Human Health, and.,Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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5
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Koeth RA, Levison BS, Culley MK, Buffa JA, Wang Z, Gregory JC, Org E, Wu Y, Li L, Smith JD, Tang WHW, DiDonato JA, Lusis AJ, Hazen SL. γ-Butyrobetaine is a proatherogenic intermediate in gut microbial metabolism of L-carnitine to TMAO. Cell Metab 2014; 20:799-812. [PMID: 25440057 PMCID: PMC4255476 DOI: 10.1016/j.cmet.2014.10.006] [Citation(s) in RCA: 374] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 09/05/2014] [Accepted: 10/13/2014] [Indexed: 01/30/2023]
Abstract
L-carnitine, a nutrient in red meat, was recently reported to accelerate atherosclerosis via a metaorganismal pathway involving gut microbial trimethylamine (TMA) formation and host hepatic conversion into trimethylamine-N-oxide (TMAO). Herein, we show that following L-carnitine ingestion, γ-butyrobetaine (γBB) is produced as an intermediary metabolite by gut microbes at a site anatomically proximal to and at a rate ∼1,000-fold higher than the formation of TMA. Moreover, we show that γBB is the major gut microbial metabolite formed from dietary L-carnitine in mice, is converted into TMA and TMAO in a gut microbiota-dependent manner (like dietary L-carnitine), and accelerates atherosclerosis. Gut microbial composition and functional metabolic studies reveal that distinct taxa are associated with the production of γBB or TMA/TMAO from dietary L-carnitine. Moreover, despite their close structural similarity, chronic dietary exposure to L-carnitine or γBB promotes development of functionally distinct microbial communities optimized for the metabolism of L-carnitine or γBB, respectively.
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Affiliation(s)
- Robert A Koeth
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA; Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Bruce S Levison
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA; Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Miranda K Culley
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA; Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Jennifer A Buffa
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA; Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Zeneng Wang
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA; Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Jill C Gregory
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA; Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Elin Org
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Yuping Wu
- Department of Mathematics, Cleveland State University, Cleveland, OH 44115, USA
| | - Lin Li
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA; Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Jonathan D Smith
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA; Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, OH 44195, USA; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
| | - W H Wilson Tang
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA; Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, OH 44195, USA; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Joseph A DiDonato
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA; Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Aldons J Lusis
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Stanley L Hazen
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA; Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, OH 44195, USA; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA.
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6
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Abstract
Myeloperoxidase (MPO) plays a central role in the innate immune system by generating leukocyte-derived oxidants to combat invading pathogens. These reactive intermediates have been increasingly recognized to be potentially deleterious, causing oxidative injury in inflammatory disease states such as cardiovascular disease. Recent evidence now suggests that circulating MPO can act as a clinical prognostic indicator for patients with cardiovascular disease.
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Wang Z, Tang WHW, Buffa JA, Fu X, Britt EB, Koeth RA, Levison BS, Fan Y, Wu Y, Hazen SL. Prognostic value of choline and betaine depends on intestinal microbiota-generated metabolite trimethylamine-N-oxide. Eur Heart J 2014; 35:904-10. [PMID: 24497336 DOI: 10.1093/eurheartj/ehu002] [Citation(s) in RCA: 411] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIMS Recent metabolomics and animal model studies show trimethylamine-N-oxide (TMAO), an intestinal microbiota-dependent metabolite formed from dietary trimethylamine-containing nutrients such as phosphatidylcholine (PC), choline, and carnitine, is linked to coronary artery disease pathogenesis. Our aim was to examine the prognostic value of systemic choline and betaine levels in stable cardiac patients. METHODS AND RESULTS We examined the relationship between fasting plasma choline and betaine levels and risk of major adverse cardiac events (MACE = death, myocardial infraction, stroke) in relation to TMAO over 3 years of follow-up in 3903 sequential stable subjects undergoing elective diagnostic coronary angiography. In our study cohort, median (IQR) TMAO, choline, and betaine levels were 3.7 (2.4-6.2)μM, 9.8 (7.9-12.2)μM, and 41.1 (32.5-52.1)μM, respectively. Modest but statistically significant correlations were noted between TMAO and choline (r = 0.33, P < 0.001) and less between TMAO and betaine (r = 0.09, P < 0.001). Higher plasma choline and betaine levels were associated with a 1.9-fold and 1.4-fold increased risk of MACE, respectively (Quartiles 4 vs. 1; P < 0.01, each). Following adjustments for traditional cardiovascular risk factors and high-sensitivity C-reactive protein, elevated choline [1.34 (1.03-1.74), P < 0.05], and betaine levels [1.33 (1.03-1.73), P < 0.05] each predicted increased MACE risk. Neither choline nor betaine predicted MACE risk when TMAO was added to the adjustment model, and choline and betaine predicted future risk for MACE only when TMAO was elevated. CONCLUSION Elevated plasma levels of choline and betaine are each associated with incident MACE risk independent of traditional risk factors. However, high choline and betaine levels are only associated with higher risk of future MACE with concomitant increase in TMAO.
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Affiliation(s)
- Zeneng Wang
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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8
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Koeth RA, Wang Z, Levison BS, Buffa JA, Org E, Sheehy BT, Britt EB, Fu X, Wu Y, Li L, Smith JD, DiDonato JA, Chen J, Li H, Wu GD, Lewis JD, Warrier M, Brown JM, Krauss RM, Tang WHW, Bushman FD, Lusis AJ, Hazen SL. Intestinal microbiota metabolism of L-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med 2013; 19:576-85. [PMID: 23563705 PMCID: PMC3650111 DOI: 10.1038/nm.3145] [Citation(s) in RCA: 2831] [Impact Index Per Article: 257.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 02/27/2013] [Indexed: 02/07/2023]
Abstract
Intestinal microbiota metabolism of choline and phosphatidylcholine produces trimethylamine (TMA), which is further metabolized to a proatherogenic species, trimethylamine-N-oxide (TMAO). We demonstrate here that metabolism by intestinal microbiota of dietary L-carnitine, a trimethylamine abundant in red meat, also produces TMAO and accelerates atherosclerosis in mice. Omnivorous human subjects produced more TMAO than did vegans or vegetarians following ingestion of L-carnitine through a microbiota-dependent mechanism. The presence of specific bacterial taxa in human feces was associated with both plasma TMAO concentration and dietary status. Plasma L-carnitine levels in subjects undergoing cardiac evaluation (n = 2,595) predicted increased risks for both prevalent cardiovascular disease (CVD) and incident major adverse cardiac events (myocardial infarction, stroke or death), but only among subjects with concurrently high TMAO levels. Chronic dietary L-carnitine supplementation in mice altered cecal microbial composition, markedly enhanced synthesis of TMA and TMAO, and increased atherosclerosis, but this did not occur if intestinal microbiota was concurrently suppressed. In mice with an intact intestinal microbiota, dietary supplementation with TMAO or either carnitine or choline reduced in vivo reverse cholesterol transport. Intestinal microbiota may thus contribute to the well-established link between high levels of red meat consumption and CVD risk.
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Affiliation(s)
- Robert A. Koeth
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Zeneng Wang
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Bruce S. Levison
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Jennifer A. Buffa
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Elin Org
- Department of Medicine/Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles 90095, USA
| | - Brendan T. Sheehy
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Earl B. Britt
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Xiaoming Fu
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Yuping Wu
- Department of Mathematics, Cleveland State University, Cleveland, Ohio 44115, USA
| | - Lin Li
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Jonathan D. Smith
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Joseph A. DiDonato
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Jun Chen
- Department of Microbiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Hongzhe Li
- Department of Microbiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Gary D. Wu
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - James D. Lewis
- Department of Microbiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Manya Warrier
- Department of Pathology, Section on Lipid Sciences, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - J. Mark Brown
- Department of Pathology, Section on Lipid Sciences, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Ronald M. Krauss
- Children’s Hospital Oakland Research Institute, Oakland, CA 94609, USA
| | - W. H. Wilson Tang
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Frederic D. Bushman
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Aldons J. Lusis
- Department of Medicine/Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles 90095, USA
| | - Stanley L. Hazen
- Department of Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic, Cleveland, Ohio 44195, USA
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Wang Z, Tang WHW, Fu X, Britt EB, Wu Y, Koeth RA, Levison B, Hazen SL. Abstract 19: Prognostic Value of Plasma Choline and Betaine Depend on the Intestinal Microflora-generated Metabolite Trimethylamine N-oxide. Arterioscler Thromb Vasc Biol 2013. [DOI: 10.1161/atvb.33.suppl_1.a19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Recent metabolomics and animal model studies show trimethylamine-N-oxide (TMAO), an intestinal microbiota-dependent metabolite formed from dietary phosphatidylcholine (PC), is linked with coronary artery disease (CAD) pathogenesis. Prognostic determinants of other PC metabolites recently associated with prevalent CAD risk, such as choline and betaine, have not been described.
Methods
We examined the relationship between fasting plasma choline, betaine, and TMAO and future risk of major adverse cardiac events (MACE=death, myocardial infraction, stroke) over 3-year follow-up in 3,916 subjects undergoing elective coronary angiography. All analytes were quantified by stable isotope dilution LC/MS/MS.
Results
In our study cohort (mean age 63±11 years, 64% male), median [IQR] TMAO, choline, and betaine levels were 3.7 [2.4-6.2] μM, 9.8 [7.9-12.2] μM, and 41.1 [32.5-52.1] μM, respectively. Modest but statistically significant correlations were noted between TMAO and choline (r=0.33, p<0.001) and between TMAO and betaine (r=0.09, p<0.001). Higher plasma TMAO, choline and betaine levels were associated with a 2.7-fold, 1.9-fold, and 1.4-fold increased risk of MACE, respectively (Quartiles 4 vs 1: p<0.01, each). Following adjustments for traditional risk factors and hsCRP, elevated TMAO (Quartiles 4 vs 1: Hazard ratio, 1.97 [95% CI 1.50-2.60], p<0.01), choline (HR 1.34 [95% CI 1.03-1.74], p<0.05) and betaine levels (HR 1.33 [95% CI 1.03-1.73], p<0.05) each predicted increased MACE risk, but only TMAO predicted MACE risk when all 3 metabolites were included in the model (HR, 1.73 [95% CI 1.3-2.31], p<0.01). Choline and betaine only predicted increased MACE risk in those with elevated TMAO levels.
Conclusion
Elevated plasma levels of TMAO, and to a lesser extent choline and betaine, are associated with incident MACE risk. However, high choline and betaine levels are only associated with higher risk of future MACE with concomitant increase in TMAO. Collectively, these findings further support the atherogenic associations between intestinal-microflora dependent metabolism of PC and atherosclerosis in humans.
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Affiliation(s)
- Zeneng Wang
- Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH
| | | | - Xiaoming Fu
- Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH
| | - Earl B Britt
- Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH
| | - Yuping Wu
- Mathematics, Cleveland State Univ, Cleveland, OH
| | - Robert A Koeth
- Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH
| | - Bruce Levison
- Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH
| | - Stanley L Hazen
- Cellular & Molecular Medicine, Cleveland Clinic, Cleveland, OH
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Abstract
BACKGROUND Recent studies in animals have shown a mechanistic link between intestinal microbial metabolism of the choline moiety in dietary phosphatidylcholine (lecithin) and coronary artery disease through the production of a proatherosclerotic metabolite, trimethylamine-N-oxide (TMAO). We investigated the relationship among intestinal microbiota-dependent metabolism of dietary phosphatidylcholine, TMAO levels, and adverse cardiovascular events in humans. METHODS We quantified plasma and urinary levels of TMAO and plasma choline and betaine levels by means of liquid chromatography and online tandem mass spectrometry after a phosphatidylcholine challenge (ingestion of two hard-boiled eggs and deuterium [d9]-labeled phosphatidylcholine) in healthy participants before and after the suppression of intestinal microbiota with oral broad-spectrum antibiotics. We further examined the relationship between fasting plasma levels of TMAO and incident major adverse cardiovascular events (death, myocardial infarction, or stroke) during 3 years of follow-up in 4007 patients undergoing elective coronary angiography. RESULTS Time-dependent increases in levels of both TMAO and its d9 isotopologue, as well as other choline metabolites, were detected after the phosphatidylcholine challenge. Plasma levels of TMAO were markedly suppressed after the administration of antibiotics and then reappeared after withdrawal of antibiotics. Increased plasma levels of TMAO were associated with an increased risk of a major adverse cardiovascular event (hazard ratio for highest vs. lowest TMAO quartile, 2.54; 95% confidence interval, 1.96 to 3.28; P<0.001). An elevated TMAO level predicted an increased risk of major adverse cardiovascular events after adjustment for traditional risk factors (P<0.001), as well as in lower-risk subgroups. CONCLUSIONS The production of TMAO from dietary phosphatidylcholine is dependent on metabolism by the intestinal microbiota. Increased TMAO levels are associated with an increased risk of incident major adverse cardiovascular events. (Funded by the National Institutes of Health and others.).
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Affiliation(s)
- W H Wilson Tang
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland 44195, USA
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Tang WHW, Wang Z, Wu Y, Fan Y, Koeth RA, Hazen S. PROGNOSTIC VALUE OF ELEVATED LEVELS OF INTESTINAL MICROFLORA-GENERATED METABOLITE TRIMETHYLAMINE N-OXIDE IN PATIENTS WITH HEART FAILURE: THE GUT HYPOTHESIS REVISITED. J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)60750-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Hong Wilson Tang W, Wang Z, Wu Y, Fan Y, Koeth RA, Hazen S. GUT FLORA METABOLITE TRIMETHYLAMINE N-OXIDE PREDICTS INCIDENT CARDIOVASCULAR RISKS IN BOTH STABLE NON-DIABETICS AND DIABETIC SUBJECTS. J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)61398-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Traditional risk factors fail to explain the increased risk for cardiovascular morbidity and mortality in ESRD. Cyanate, a reactive electrophilic species in equilibrium with urea, posttranslationally modifies proteins through a process called carbamylation, which promotes atherosclerosis. The plasma level of protein-bound homocitrulline (PBHCit), which results from carbamylation, predicts major adverse cardiac events in patients with normal renal function, but whether this relationship is similar in ESRD is unknown. We quantified serum PBHCit in a cohort of 347 patients undergoing maintenance hemodialysis with 5 years of follow-up. Kaplan-Meier analyses revealed a significant association between elevated PBHCit and death (log-rank P<0.01). After adjustment for patient characteristics, laboratory values, and comorbid conditions, the risk for death among patients with PBHCit values in the highest tertile was more than double the risk among patients with values in the middle tertile (adjusted hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.5-3.9) or the lowest tertile (adjusted HR, 2.3; 95% CI, 1.5-3.7). Including PBHCit significantly improved the multivariable model, with a net reclassification index of 14% (P<0.01). In summary, serum PBHCit, a footprint of protein carbamylation, predicts increased cardiovascular risk in patients with ESRD, supporting a mechanistic link among uremia, inflammation, and atherosclerosis.
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Affiliation(s)
- Robert A Koeth
- Department of Cellular & Molecular Medicine, Cleveland Clinic, 4500 Euclid Avenue, NC-10, Cleveland, OH 44195, USA
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