Plasma levels of trimethylamine-N-oxide can be increased with 'healthy' and 'unhealthy' diets and do not correlate with the extent of atherosclerosis but with plaque instability

Cardiovasc Res. 2021 Jan 21;117(2):435-449. doi: 10.1093/cvr/cvaa094.


Aims: The microbiome-derived metabolite trimethylamine-N-oxide (TMAO) has attracted major interest and controversy both as a diagnostic biomarker and therapeutic target in atherothrombosis.

Methods and results: Plasma TMAO increased in mice on 'unhealthy' high-choline diets and notably also on 'healthy' high-fibre diets. Interestingly, TMAO was found to be generated by direct oxidation in the gut in addition to oxidation by hepatic flavin-monooxygenases. Unexpectedly, two well-accepted mouse models of atherosclerosis, ApoE-/- and Ldlr-/- mice, which reflect the development of stable atherosclerosis, showed no association of TMAO with the extent of atherosclerosis. This finding was validated in the Framingham Heart Study showing no correlation between plasma TMAO and coronary artery calcium score or carotid intima-media thickness (IMT), as measures of atherosclerosis in human subjects. However, in the tandem-stenosis mouse model, which reflects plaque instability as typically seen in patients, TMAO levels correlated with several characteristics of plaque instability, such as markers of inflammation, platelet activation, and intraplaque haemorrhage.

Conclusions: Dietary-induced changes in the microbiome, of both 'healthy' and 'unhealthy' diets, can cause an increase in the plasma level of TMAO. The gut itself is a site of significant oxidative production of TMAO. Most importantly, our findings reconcile contradictory data on TMAO. There was no direct association of plasma TMAO and the extent of atherosclerosis, both in mice and humans. However, using a mouse model of plaque instability we demonstrated an association of TMAO plasma levels with atherosclerotic plaque instability. The latter confirms TMAO as being a marker of cardiovascular risk.

Keywords: Atherosclerosis; Bacterial microbiome; TMAO; Unstable plaque.

Publication types

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

MeSH terms

  • Animal Feed
  • Animals
  • Atherosclerosis / blood*
  • Atherosclerosis / diagnostic imaging
  • Atherosclerosis / microbiology
  • Atherosclerosis / pathology
  • Bacteria / metabolism*
  • Biomarkers / blood
  • Carotid Artery Diseases / blood
  • Carotid Artery Diseases / diagnostic imaging
  • Carotid Artery Diseases / microbiology
  • Choline / administration & dosage*
  • Choline / metabolism
  • Choline / toxicity
  • Coronary Artery Disease / blood
  • Coronary Artery Disease / diagnostic imaging
  • Coronary Artery Disease / microbiology
  • Diet, Healthy*
  • Dietary Fiber / administration & dosage*
  • Dietary Fiber / metabolism
  • Disease Models, Animal
  • Dysbiosis
  • Gastrointestinal Microbiome*
  • Heart Disease Risk Factors
  • Humans
  • Male
  • Methylamines / blood*
  • Mice
  • Mice, Inbred C57BL
  • Mice, Knockout, ApoE
  • Plaque, Atherosclerotic*
  • Receptors, LDL / genetics
  • Receptors, LDL / metabolism
  • Rupture, Spontaneous
  • Vascular Calcification / blood
  • Vascular Calcification / diagnostic imaging
  • Vascular Calcification / microbiology


  • Biomarkers
  • Dietary Fiber
  • Methylamines
  • Receptors, LDL
  • trimethyloxamine
  • Choline