Probiotic Bifidobacterium reduces serum TMAO in unstable angina patients via the gut to liver to heart axis

Abstract

Background and aims: Studies indicate that the gut microbiota and its metabolites are involved in the progression of cardiovascular diseases, and enterohepatic circulation plays an important role in this progression. This study aims to identify potential probiotics for the treatment of unstable angina (UA) and elucidate their mechanisms of action.

Methods: Initially, the gut microbiota from patients with UA and control was analyzed. To directly assess the effects of Bifidobacterium supplementation, 10 patients with UA were enrolled and administered Bifidobacterium (630 mg per intake twice a day for 1 month). The fecal metagenome, serum trimethylamine N-oxide (TMAO) levels, and other laboratory parameters were evaluated before and after Bifidobacterium supplementation.

Results: After supplementing with Bifidobacterium for 1 month, there were statistically significant differences (P < 0.05) in TMAO, aspartate aminotransferase, total cholesterol, and low-density lipoprotein compared to before. Additionally, the abundance of Bifidobacterium longum increased significantly, although the overall abundance of Bifidobacterium did not reach statistical significance. The gut microbiota, metabolites, and gut-liver axis are involved in the progression of UA, and potential mechanisms should be further studied.

Conclusions: Metagenomic analysis demonstrated a reduced abundance of Bifidobacterium in patients with UA. Supplementation with Bifidobacterium restored gut dysbiosis and decreased circulating TMAO levels in patients with UA. This study provides evidence that Bifidobacterium may exert cardiovascular-protective effects through the gut—liver—heart axis.

Keywords

Gut—liver—heart axis / Bifidobacterium / Unstable angina pectoris / Trimethylamine N-oxide (TMAO)

Authors’ Contribution

Zhihong Zhou, Lizhe Sun, and Wei Zhou contributed equally to this paper and should be considered co-first authors. Zhihong Zhou: Visualization, Software, Methodology, Investigation. Lizhe Sun: Writing e original draft, Software, Methodology. Wei Zhou: Formal analysis, Data curation. Wen Gao: Data curation. Xiao Yuan: Investigation, Data curation. Huijuan Zhou: Methodology. Yuzhen Ren: Data curation. Bihua Li: Data curation. Yue Wu: Writing e review & editing, Project administration. Jianqing She: Writing e review & editing, Supervision, Project administration, Funding acquisition. All of the authors approved the final manuscript.

Data availability

The study protocol, standard operating procedures, and data that support the findings of this study are available from the cor-responding author upon reasonable request.

Declaration of competing interest

The authors declare that there is no conflicts of interest.

Acknowledgements

This study was supported by the Inner Mongolia Autonomous Region Science and Technology Plan Project (No. 2020GG0278), Bayannur City Science and Technology Plan Project (No. K202331), the Clinical Research Award of the First Affiliated Hospital of Xi’an Jiaotong University (No. XJTU1AF2021CRF-007) and Key Research and Development Program of Shaanxi (Program No. 2022JQ-797). We thank Novogene Co., Ltd. for their assistance during targeted metabolomic analysis. Schematic diagrams were generated by Biorender.com.

References

[1] Timmis A, Kazakiewicz D, Townsend N, Huculeci R, Aboyans V, Vardas P. Global epidemiology of acute coronary syndromes. Nat Rev Cardiol. 2023;20:778-788. https://doi.org/10.1038/s41569-023-00884-0.

[2] Xue H, Chen X, Yu C, et al. Gut microbially produced indole-3-propionic acid inhibits atherosclerosis by promoting reverse cholesterol transport and its deficiency is causally related to atherosclerotic cardiovascular disease. Circ Res. 2022;131:404-420. https://doi.org/10.1161/circresaha.122.321253.

[3] Chen Y, Zhou J, Wang L. Role and mechanism of gut microbiota in human disease. Front Cell Infect Microbiol. 2021;11:625913. https://doi.org/10.3389/fcimb.2021.625913.

[4] Tousoulis D, Guzik T, Padro T, et al. Mechanisms, therapeutic implications, and methodological challenges of gut microbiota and cardiovascular diseases: a position paper by the ESC Working Group on Coronary Pathophysiology and Microcirculation. Cardiovasc Res. 2022;118:3171-3182. https://doi.org/10.1093/cvr/cvac057.

[5] Liu R, Hong J, Xu X, et al. Gut microbiome and serum metabolome alterations in obesity and after weight-loss intervention. Nat Med. 2017;23:859-868. https://doi.org/10.1038/nm.4358.

[6] Miyauchi E, Shimokawa C, Steimle A, Desai MS, Ohno H. The impact of the gut microbiome on extra-intestinal autoimmune diseases. Nat Rev Immunol. 2023;23:9-23. https://doi.org/10.1038/s41577-022-00727-y.

[7] Janeiro MH, Ramírez MJ, Milagro FI, Martínez JA, Solas M. Implication of tri-methylamine N-oxide (TMAO) in disease: potential biomarker or new thera-peutic target. Nutrients. 2018; 10. https://doi.org/10.3390/nu10101398.

[8] Oh J, Kim J, Lee S, et al. 1H NMR serum metabolomic change of trimethylamine N- oxide (TMAO) is associated with alcoholic liver disease progression. Me-tabolites. 2024;14:39. https://doi.org/10.3390/metabo14010039.

[9] Chen YM, Liu Y, Zhou RF, et al. Associations of gut-flora-dependent metabolite trimethylamine-N-oxide, betaine and choline with non-alcoholic fatty liver disease in adults. Sci Rep. 2016;6:19076. https://doi.org/10.1038/srep19076.

[10] Leon-Mimila P, Villamil-Ramírez H, Li XS, et al. Trimethylamine N-oxide levels are associated with NASH in obese subjects with type 2diabetes. Diabetes Metab. 2021;47:101183. https://doi.org/10.1016/j.diabet.2020.07.010.

[11] Gilbert MC, Setayesh T, Wan YY. The contributions of bacteria metabolites to the development of hepatic encephalopathy. Liver Res. 2023;7:296-303. https://doi.org/10.1016/j.livres.2022.11.005.

[12] Wang Z, Klipfell E, Bennett BJ, et al. Gut flora metabolism of phosphatidyl-choline promotes cardiovascular disease. Nature. 2011;472:57-63. https://doi.org/10.1038/nature09922.

[13] Mantovani A, Csermely A, Petracca G, et al. Non-alcoholic fatty liver disease and risk of fatal and non-fatal cardiovascular events: an updated systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2021;6:903-913. https://doi.org/10.1016/S2468-1253(21)00308-3.

[14] Canakis A, Haroon M, Weber HC. Irritable bowel syndrome and gut microbiota. Curr Opin Endocrinol Diabetes Obes. 2020;27:28-35. https://doi.org/10.1097/med.0000000000000523.

[15] Allayee H, Hazen SL. Contribution of gut bacteria to lipid levels: another metabolic role for microbes? Circ Res. 2015;117:750-754. https://doi.org/10.1161/circresaha.115.307409.

[16] Al-Obaide MAI, Singh R, Datta P, et al. Gut Microbiota-dependent trimethyl-amine-N-oxide and serum biomarkers in patients with T2DM and advanced CKD. J Clin Med. 2017;6:86. https://doi.org/10.3390/jcm6090086.

[17] McCarthy RE, Bowen DG, Strasser SI, McKenzie C. The dangers of herbal weight loss supplements: a case report of drug-induced liver injury secondary to Garcinia cambogia ingestion. Pathology. 2021;53:545-547. https://doi.org/10.1016/j.pathol.2020.08.021.

[18] Azevedo RD, Reis F. Transient bilateral striatal lesion associated with varicella infection. Radiol Bras. 2017;50:347-348. https://doi.org/10.1590/0100-3984.2016.0058.

[19] Cordier F, Lapeire L, Sys G, Van Dorpe J, Creytens D. A challenging case of a poorly differentiated small cell variant of synovial sarcoma with unusual immunophenotype. Pathology. 2021;53:658-660. https://doi.org/10.1016/j.pathol.2020.08.028.

[20] Mailer RKW, Gisterå A, Polyzos KA, Ketelhuth DFJ, Hansson GK. Hypercholes-terolemia induces differentiation of regulatory T cells in the liver. Circ Res. 2017;120:1740-1753. https://doi.org/10.1161/circresaha.116.310054.

[21] Sarkar A, Rafiq K. Humoral immunity in heart failure. Cardiovasc Hematol Disord Drug Targets. 2019;19:14-18. https://doi.org/10.2174/1871529x18666180518101527.

[22] Adak A, Khan MR. An insight into gut microbiota and its functionalities. Cell Mol Life Sci. 2019;76:473-493. https://doi.org/10.1007/s00018-018-2943-4.

[23] Zhu W, Gregory JC, Org E, et al. Gut microbial metabolite TMAO enhances platelet hyperreactivity and thrombosis risk. Cell. 2016;165:111-124. https://doi.org/10.1016/j.cell.2016.02.011.

[24] Crimarco A, Springfield S, Petlura C, et al. A randomized crossover trial on the effect of plant-based compared with animal-based meat on trimethylamine-N-oxide and cardiovascular disease risk factors in generally healthy adults: Study With Appetizing Plantfood-Meat Eating Alternative Trial (SWAP-MEAT). Am J Clin Nutr. 2020;112:1188-1199. https://doi.org/10.1093/ajcn/nqaa203.

[25] Saaoud F, Liu L, Xu K, et al. Aorta- and liver-generated TMAO enhances trained immunity for increased inflammation via ER stress/mitochondrial ROS/glycolysis pathways. JCI Insight. 2023;8:e158183. https://doi.org/10.1172/jci.insight.158183.

[26] Tang WH, Wang Z, Levison BS, et al. Intestinal microbial metabolism of phos-phatidylcholine and cardiovascular risk. N Engl J Med. 2013;368:1575-1584. https://doi.org/10.1056/NEJMoa1109400.

[27] She J, Tuerhongjiang G, Guo M, et al. Statins aggravate insulin resistance through reduced blood glucagon-like peptide-1 levels in a microbiota-dependent manner. Cell Metab. 2024;36:408-421. https://doi.org/10.1016/j.cmet.2023.12.027(e405).

[28] Abid MB, Koh CJ. Probiotics in health and disease: fooling mother nature? Infection. 2019;47:911-917. https://doi.org/10.1007/s15010-019-01351-0.

[29] Sadeghzadeh J, Vakili A, Sameni HR, Shadnoush M, Bandegi AR,Zahedi Khorasani M. The effect of oral consumption of probiotics in prevention of heart injury in a rat myocardial infarction model: a histopathological, hemo-dynamic and biochemical evaluation. Iran Biomed J. 2017;21:174-181. https://doi.org/10.18869/acadpub.ibj.21.3.174.

[30] Hmar EBL, Paul S, Sharma HK. An insight into the combination of probiotics and their implications for human health. Endocr Metab Immune Disord Drug Targets. 2024;24:1-12. https://doi.org/10.2174/1871530323666230502141717.

[31] Quigley EMM. Prebiotics and probiotics in digestive health. Clin Gastroenterol Hepatol. 2019;17:333-344. https://doi.org/10.1016/j.cgh.2018.09.028.

[32] Wang G, Jiao T, Xu Y, et al. Bifidobacterium adolescentis and Lactobacillus rhamnosus alleviate non-alcoholic fatty liver disease induced by a high-fat, high-cholesterol diet through modulation of different gut microbiota-dependent pathways. Food Funct. 2020;11:6115-6127. https://doi.org/10.1039/c9fo02905b.

[33] Bourgin M, Kriaa A, Mkaouar H, et al. Bile salt hydrolases: at the crossroads of microbiota and human health. Microorganisms. 2021;9:1122. https://doi.org/10.3390/microorganisms9061122.

[34] Bustamante JM, Dawson T, Loeffler C, et al. Impact of fecal microbiota trans-plantation on gut bacterial bile acid metabolism in humans. Nutrients. 2022; 14. https://doi.org/10.3390/nu14245200.

[35] Lugli GA, Milani C, Duranti S, et al. Isolation of novel gut bifidobacteria using a combination of metagenomic and cultivation approaches. Genome Biol. 2019;20:96. https://doi.org/10.1186/s13059-019-1711-6.

[36] Yang M, Gu Y, Li L, et al. Bile acid-gut microbiota axis in inflammatory bowel disease: from bench to bedside. Nutrients. 2021;13:3143. https://doi.org/10.3390/nu13093143.

[37] Chan YK, Brar MS, Kirjavainen PV, et al. High fat diet induced atherosclerosis is accompanied with low colonic bacterial diversity and altered abundances that correlates with plaque size, plasma A-FABP and cholesterol: a pilot study of high fat diet and its intervention with lactobacillus rhamnosus GG (LGG) or telmisartan in ApoE-/- mice. BMC Microbiol. 2016;16:264. https://doi.org/10.1186/s12866-016-0883-4.

[38] Stepankova R, Tonar Z, Bartova J, et al. Absence of microbiota (germ-free conditions) accelerates the atherosclerosis in ApoE-deficient mice fed standard low cholesterol diet. J Atherosclerosis Thromb. 2010;17:796-804. https://doi.org/10.5551/jat.3285.

[39] Guasti L, Galliazzo S, Molaro M, et al. TMAO as a biomarker of cardiovascular events: a systematic review and meta-analysis. Intern Emerg Med. 2021;16: 201-207. https://doi.org/10.1007/s11739-020-02470-5.

[40] Zhen J, Zhou Z, He M, et al. The gut microbial metabolite trimethylamine N-oxide and cardiovascular diseases. Front Endocrinol (Lausanne). 2023;14: 1085041. https://doi.org/10.3389/fendo.2023.1085041.

[41] Li D, Lu Y, Yuan S, et al. Gut microbiota-derived metabolite trimethylamine-N-oxide and multiple health outcomes: an umbrella review and updated meta-analysis. Am J Clin Nutr. 2022;116:230-243. https://doi.org/10.1093/ajcn/nqac074.

[42] Wang M, Li XS, Wang Z, et al. Trimethylamine N-oxide is associated with long-term mortality risk: the multi-ethnic study of atherosclerosis. Eur Heart J. 2023;44:1608-1618. https://doi.org/10.1093/eurheartj/ehad089.

[43] Marques FZ, Nelson E, Chu PY, et al. High-fiber diet and acetate supplemen-tation change the gut microbiota and prevent the development of hyperten-sion and heart failure in hypertensive mice. Circulation. 2017;135:964-977. https://doi.org/10.1161/CIRCULATIONAHA.116.024545.

[44] Gao Y, Lin J, Ye C, Guo S, Jiang C. Microbial transformations of bile acids and their receptors in the regulation of metabolic dysfunction-associated steatotic liver disease. Liver Res. 2023;7:165-176. https://doi.org/10.1016/j.livres.2023.09.002.