Association of endotoxemia with carotid atherosclerosis and cardiovascular disease: prospective results from the Bruneck Study

J Am Coll Cardiol. 1999 Dec;34(7):1975-81. doi: 10.1016/s0735-1097(99)00448-9.


Objectives: Focus of the current study was on the significance of bacterial endotoxin, which shows a variety of pro-atherogenic properties and may occur at high concentration in the circulation of infected subjects.

Background: The possibility of an infectious risk factor in atherogenesis and cardiovascular disease has stimulated research interest, but the nature of such process remains obscure.

Methods: We measured plasma endotoxin levels (LAL assay) in a random population of 516 men and women 50 to 79 years old at the 1990 baseline evaluation (Bruneck Study). End points of this prospective survey were incident (early) atherosclerosis in the carotid arteries as assessed with high-resolution Duplex ultrasound (five-year follow-up rate, 98%) and incident cardiovascular disease (follow-up rate, 100%).

Results: Median endotoxin concentration amounted to 14.3 pg/ml (range, 6.0 to 209.2 pg/ml). Subjects with levels beyond 50 pg/ml (90th percentile) faced a threefold risk of incident atherosclerosis (odds ratio [95% confidence interval] 2.9 [1.4-6.3]; p < 0.01). The risk associated with high endotoxin was most pronounced in subjects with chronic infections and in current and ex-smokers. Notably, smokers with low endotoxin levels and nonsmokers did not differ in their atherosclerosis risk, whereas smokers with high levels almost invariably developed new lesions. All findings emerged as independent of vascular risk factors. Similar results were obtained for incident cardiovascular disease.

Conclusions: The current study yields first epidemiologic evidence that endotoxemia constitutes a strong risk factor of early atherogenesis in subjects with chronic or recurrent bacterial infections and a link in the association between cigarette smoking and atherosclerotic disease.

Publication types

  • Clinical Trial
  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Bacterial Infections / blood
  • Bacterial Infections / complications*
  • Bacterial Infections / epidemiology
  • Blood Flow Velocity
  • Cardiovascular Diseases / epidemiology
  • Cardiovascular Diseases / etiology*
  • Carotid Artery Diseases / epidemiology
  • Carotid Artery Diseases / etiology*
  • Carotid Artery Diseases / physiopathology
  • Carotid Artery, Internal* / diagnostic imaging
  • Chronic Disease
  • Endotoxemia / blood
  • Endotoxemia / complications*
  • Endotoxemia / epidemiology
  • Endotoxins / blood
  • Female
  • Humans
  • Incidence
  • Italy / epidemiology
  • Limulus Test
  • Male
  • Middle Aged
  • Odds Ratio
  • Prevalence
  • Prospective Studies
  • Risk Factors
  • Surveys and Questionnaires
  • Survival Rate
  • Ultrasonography, Doppler, Duplex


  • Endotoxins