Gut Microbiota
and
Atherothrombotic
Heart Disease
Stanley L Hazen, MD, PhD
Section Head, Preventive
Cardiology, Cleveland Clinic
Chair, Dept. of Cellular &
Molecular Medicine, Lerner
Research Institute,
Cleveland Clinic
Drugs for Bugs
Drugging the Microbiome
Disclosures:
all research presented was funded by the
NIH and the Office of Dietary Supplements
• Dr. Hazen is named as a co-inventor on pending and issued patents
held by the Cleveland Clinic relating to cardiovascular diagnostics
and/or therapeutics.
• Dr. Hazen reports having been paid as a consultant for the following
companies: Esperion, and Procter & Gamble.
• Dr. Hazen reports receiving research funds or support from Abbott,
Astra Zeneca, Pfizer, Procter & Gamble, Roche, and Takeda.
• Dr. Hazen reports having the right to receive royalty payments for
inventions or discoveries related to cardiovascular diagnostics
and/or therapeutics from Cleveland Heart Laboratory, Esperion,
Frantz Biomarkers, LLC and Siemens.
• Dr. Hazen was the scientific founder of Cleveland Heart Laboratory,
and reports having equity in that company.
some take
home
concepts:
The human body is an
integrated circuit btw
our gut microbes and
our human genes
Gut flora
●
Dietary choline
and L-carnitine
TMA
The microbiome is a
filter of our largest
environmental exposure
– what we eat
●
The microbiome can
be considered as our
largest endocrine organ
TMAO
●
The microbiome is a
“drugable” target
Hepatic
FMOs
choline
carnitine
Heart
Attack
Atherosclerosis
●
Heart
Failure
CKD
Diet and Intestinal Microbes are Mechanistically
Linked to Atherosclerotic Heart Disease
Meta-organismal pathway:
(i) gut microbe
(ii) host hepatic
:
FMOs
carnitine
Trimethylamine
(TMA)
Z Wang (2011) Nature
carnitine
RA Koeth (2013) Nature Medicine
WHW Tang (2013) New Engl J Med
B Bennett (2013) Cell Metab
(TMAO)
Z Wang (2014) Eur Heart J
WHW Tang (2014) JACC
RA Koeth (2014) Cell Metab
WHW Tang (2015) Circ Res
M Warrier (2015) Cell Reports
J Gregory (2015) J Biol Chem
Z Wang (2015) Cell
4
C Organ (2016) Circ Heart Fail
W Zhu (2016) Cell
TMAO alters macrophage phenotype, EC activation and
sterol metabolism in multiple compartments
ATHEROSCLEROSIS
FORWARD TRANSPORT
REVERSE TRANSPORT

 Cholesterol
storage
EC activation
 macrophage
phenotype
 sterol/bile
transporters
 bile acid
composition,
pool size and
transporters
 LXR and
FXR signaling
adapted from:
R Koeth et al, Nature Medi (2013), Warrier et al, Cell Reports (2015), Seldin et al, JAHA (2016)
The gut microbial TMAO pathway contributes to the development of
“The Vulnerable Patient”
A
Adverse cardiac event
Adverse Cardiovascular Event
Stroke
Intracoronary
thrombosis
Heart failure
EC activation
W Zhu et al. Gut microbial choline metabolite TMAO enhances platelet hyperreactivity
and thrombosis risk. Cell March 24, 2016
Elevated plasma levels of TMAO predict incident risk for
thrombotic events (myocardial infarction and stroke)
N=4007 sequential subjects undergoing
cardiac evaluations, 3-year follow up
Xinmin Li, PhD
Adjusted for traditional risk factors include age, gender, systolic blood pressure, meds,
7
BMI, LDLc, HDLc, smoking, DM, TG, eGFR, CVD
Zhu et al, Cell (2016)
Brief exposure to TMAO enhances human platelet
responsiveness to multiple agonists
Platelet rich
plasma
Weifei Zhu, PhD
Washed human
platelets
8
Zhu et al, Cell (2016)
TMAO enhances stimulus dependent Ca2+ release in platelets
Diet 
Change in microbial community
composition and function
9
Zhu et al, Cell (2016)
Carotid artery injury in vivo
thrombosis model
- Internal carotid artery cut down
- Vital microscopy imaging of
fluorescent labeled platelets
Dietary choline enhances thrombosis
susceptibility in vivo
Carotid
artery
Jugular
vein
10
Zhu et al, Cell (2016)
Plasma levels of TMAO show a strong correlation
with in vivo thrombosis rates
r = -0.60
p < 0.001
pro-thrombotic
11
Zhu et al, Cell (2016)
Choline TMA Lyase (CutC/D)
Carnitine TMA Lyase (Cnt A/B)
Promiscuous TMA Lyase (yeaX/W)
Brown JM and Hazen SL. The Gut Microbial Endocrine Organ: Bacterially-Derived
Signals Driving Cardiometabolic Diseases. (2015) Annu Rev Med.
“Let food be thy medicine and medicine be thy food.”
Hippacrates, Father of Western Medicine
431 B.C.
What are Dietary Sources of Choline/Phosphatidylcholine?
Lekithos (Greek) = Egg yolk
Chole (Greek) = Bile
Li & Vance, J Lipid
Res 2008
Chronic Dietary Choices Impact TMAO Levels
De Filippis et al, Gut 2015
Choline TMA Lyase (CutC/D)
Carnitine TMA Lyase (Cnt A/B)
Promiscuous TMA Lyase (yeaX/W)
Brown JM and Hazen SL. The Gut Microbial Endocrine Organ: Bacterially-Derived
Signals Driving Cardiometabolic Diseases. (2015) Annu Rev Med.
Choline TMA Lyase (CutC/D)
Carnitine TMA Lyase (Cnt A/B)
Promiscuous TMA Lyase (yeaX/W)
Brown JM and Hazen SL. The Gut Microbial Endocrine Organ: Bacterially-Derived
Signals Driving Cardiometabolic Diseases. (2015) Annu Rev Med.
Development of inhibitors (and activators) of
microbial TMA lyases
choline
Wang et al, Cell (2015)
Sources of DMB
Olives/Cold-pressed extra virgin olive oil
Grape seed oil
Guinness Lager
Stout
DMB is a non-lethal microbial TMA lyase inhibitor in multiple
human commensals
A
B
P. mirabilis
P. penneri
E. fergusonii
C
1.4
1.2
intact cell
p=0.0007
p=0.007
p=0.009
0.8
0.7
0.4
3
DMB
0.0
0
8
16
Time (h)
24
0.0
0
Time (h)
4
8
Time (h)
Wang et al, Cell (2015)
12
Microbial TMA-lyase inhibition reduces TMAO levels in vivo
C57Blk/6J, apoE-/- mice
diet:
Wang et al, Cell (2015)
Microbial TMAO lyase inhibition attenuates dietary
choline enhanced atherosclerosis
C57BL/6J ApoE-/- mice, male
a
b
choline
p=0.27
60000
p=0.003
p=0.006
50000
40000
30000
chow+DMB
choline+DMB
20000
10000
0
Chow
(n=32)
choline
(n=23)
Chow
+DMB
(n=20)
choline
+DMB
(n=20)
Wang et al, Cell (2015)
Drugging the Microbiome – Its in Our Future
for
CVD Therapeutics
Inhibitor
TMAO
Z Wang et al, Cell, Dec 17, 2015
Thank you
Hazen Lab
The Cleveland Clinic
Zeneng Wang
Jennifer Buffa
Robert Koeth Manya Warrier
Bruce Levison Mark Brown
Xinmin Li
WeiFei Zhu
UCLA
Wilson Tang
Jake Lusis
Joe DiDonato
Elin Org
Jill Gregory
Diana Shih
Drugs for Bugs
Drugging the Microbiome
Thank you