Trimethylamine N-Oxide and Mortality Risk in Patients With Peripheral Artery Disease

J Am Heart Assoc. 2016 Oct 19;5(10):e004237. doi: 10.1161/JAHA.116.004237.


Background: Production of the proatherogenic metabolite, trimethylamine N-oxide (TMAO), from dietary nutrients by intestinal microbiota enhances atherosclerosis development in animal models and is associated with atherosclerotic coronary artery disease in humans. The utility of studying plasma levels of TMAO to risk stratify in patients with peripheral artery disease (PAD) has not been reported.

Methods and results: We examined the relationship between fasting plasma TMAO and all-cause mortality (5-year), stratified by subtypes of PAD and presence of coronary artery disease in 935 patients with PAD who underwent elective angiography for cardiac evaluation at a tertiary care hospital. Median plasma TMAO was 4.8 μmol/L (interquartile range, 2.9-8.0 μmol/L). Elevated TMAO levels were associated with 2.7-fold increased mortality risk (fourth versus first quartiles, hazard ratio 2.86, 95% CI 1.82-3.97, P<0.001). Following adjustments for traditional risk factors, inflammatory biomarkers, and history of coronary artery disease, the highest TMAO quartile remained predictive of 5-year mortality (adjusted hazard ratio 2.06, 95% CI 1.36-3.11, P<0.001). Similar prognostic value for elevated TMAO was seen for subjects with carotid artery, non-carotid artery, or lower extremity PAD. TMAO provided incremental prognostic value for all-cause mortality (net reclassification index, 40.22%; P<0.001) and improvement in area under receiver operator characteristic curve (65.7% versus 69.4%; P=0.013).

Conclusions: TMAO, a pro-atherogenic metabolite formed by gut microbes, predicts long-term adverse event risk and incremental prognostic value in patients with PAD. These findings point to the potential for TMAO to help improve selection of high-risk PAD patients with or without significant coronary artery disease, who likely need more aggressive and specific dietary and pharmacologic therapy.

Keywords: intestinal microbiota; peripheral vascular disease; trimethylamine N‐oxide; vascular biology.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Carotid Stenosis / diagnostic imaging
  • Carotid Stenosis / epidemiology*
  • Cause of Death
  • Cohort Studies
  • Computed Tomography Angiography
  • Coronary Angiography
  • Coronary Artery Disease / diagnostic imaging
  • Coronary Artery Disease / epidemiology*
  • Female
  • Gastrointestinal Microbiome*
  • Humans
  • Kaplan-Meier Estimate
  • Lower Extremity / blood supply
  • Magnetic Resonance Angiography
  • Male
  • Methylamines / blood*
  • Middle Aged
  • Mortality*
  • Peripheral Arterial Disease / blood*
  • Peripheral Arterial Disease / epidemiology
  • Prognosis
  • Proportional Hazards Models
  • Risk
  • Risk Assessment
  • Ultrasonography
  • United States / epidemiology


  • Methylamines
  • trimethyloxamine