HELICOBACTER PYLORI and CORONARY ARTERY DISEASE

PHUNG TRONG KIENMEDIC MEDICAL CENTER

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CONTENTS

Review. Relation between H. pylori

infection and coronary artery disease. Pathogenic mechanisms. Treatment. Conclusion.

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REVIEW

INFLAMMATORY TRIGGERS OF ATHEROSCLEROSIS:

NON-INFECTIOUS: - Modified lipoproteins (e,g: oxidized low-density

lipoproteins). - Diabetes. - Hypertension (mechanical stress). - Products of cigarette smoke. - Sympatho-adrenal activation (physical, emotinal stress). - Neuro-endocrine factors (increased angiotensin-II). - Hyperhomocysteinemia. - Renal insufficiency, uremic factors. - Other inflammatory mediators, cytokines, oxidants. (Jeffrey L. Anderson: The role of Infection, chapter 7, from Pierre

Theroux’s Acute coronary syndromes, page 89, Saunders (USA), copyright 2003.)

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INFLAMMATORY TRIGGERS OF ATHEROSCLEROSIS:

VIRUSES: - Cytomegalovirus. - Herpes simplex virises (HSV-1, HSV-2). - Epstein-Barr virus. - Hepatitis A. - Human immunodeficiency virus (HIV). - Influenza. BACTERIA: - Chlamydia pneumoniae. - Helicobacter pylori. - Priodontal disease (e.g Porphyromonas gingivalis, Streptococcus

sanguis, Streptococcus viridans). - Mycoplasma pneumoniae. - Hemophilus influenzae. - Chronic bacterial respiratory, urinary, dental, other infections. (Jeffrey L. Anderson: The role of Infection, chapter 7, from Pierre

Theroux’ s Acute coronary syndromes, page 89, Saunders (USA), copyright 2003.)

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MOLECULAR AND CELLULAR MECHANISMS BY WHICH NFECTIOUS AGENTS MAY PROMOTE ATHEROSCLEROSIS: Stimulate inflammation: - ↑Local and circulating inflammatory mediators: +↑Chemokines, Cytokines, adhesion molecules. +↑Matrix-degrading proteases. - Pathogen (or pathogen-product) directed immune responses. - Host-directed (auto-immune) responses (molecular mimickry). Lipid accumulalion: - ↑Scavenger receptor activity. - ↓Cholesterol esterase activity. Endothelial Dysfunction: - Impaired vasodilator function. - ↓Anticoagulant activity, ↑procoagulant effects. Smooth Muscle Cell (SMC) Accumulation: - ↑SMC proliferation: + P53 inhibition. + Growth factor/ receptor expression. - ↑SMC migration. - ↓SMC apoptosis: + P53 inhibition.

(Jeffrey L. Anderson: The role of Infection, chapter 7, from Pierre Theroux’ s Acute coronary syndromes, page 96, Saunders (USA), copyright 2003.)

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Helicobacter pylori: Helicobacter pylori is a gram-negative

microaerophilic bacillus. It measures 0.5 mm to 1.0 mm in diameter by 2.5 mm to 5.0 mm long. It requires an atmosphere of 5% O2 and 5% to 10% CO2.

Its morphology is heterogeneous: it can take a helicoidal, spiral, or curved shape, with 2 to 6 flagella.

In aged cultures it tends to present in coccoid form. It products a urease that, via the production of

ammonia, creates a microenvironment with a pH greater than that of gastric mucous, allowing it to survive.

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REVIEW

Helicobacter pylori: It is considered the etiopathogenic agent

of both benign and malignant gastro duodenal disease. In fact, it has been classified as a type 1 carcinogen by the World Health Organization (WHO).

In recent years it has been proposed that H. pylori has a role in the atherothrombotic process.

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Case-control epidemiological studies:

- Mendall M et al (Br Heart J 1994;71:437-9): A greater prevalence of infection by H. pylori in

patients with coronary cardiopathy and in patients with cerebrovascular ischemia.

- Pasceri et al (Circulation 1998;97:1675-9): Revealed a greater prevalence of infection by strains

of H. pylori cagA+ in patients with coronary cardiopathy vs a control group, while the prevalence of infection by strains of cagA– did not reveal differences between the patients and the control group.

RELATION BETWEEN H. PYLORI INFECTION AND CORONARY ARTERY DISEASE

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RELATION BETWEEN H. PYLORI INFECTION AND CORONARY ARTERY DISEASE

- Kowalski M, Konturek JW et al [J Physiol Pharmacol 1999; 50

( Suppl 2): A28]: Frequency of the Hp

infection in patients with coronariographically confirmed CAD (one- to three-vessel-disease and PTCA or CABG in the past) was significantly higher than in the healthy population of similar age and gender.

Case-control epidemiological studies:

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RELATION BETWEEN H. PYLORI INFECTION AND CORONARY ARTERY DISEASE

The seroprevalence of H. pylori and markers of inflammatory processes: - Niemëla et al (Heart 1996;75:573-5): Found significant differences between triglyceride and

HDL values among seropositive and seronegative subjects vs H. pylori.

- Patel et al (BMJ 1995;311:711-4): Found a significant increase in fibrinogen in seropositive

patients, but did not find differences in the plasma cholesterol or triglyceride values.

- Ossei-Gerning N et al (Cardiovasc Res 1997;35:120-4):

Factor VII has also been studied, but no significant differences have been found among patients seropositive for H. pylori with regard to those who were seronegative.

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RELATION BETWEEN H. PYLORI INFECTION AND CORONARY ARTERY DISEASE

The seroprevalence of H. pylori and markers of inflammatory

processes:

- Rengström et al (J Int Med 1998;243:109-13): Did not observe significant differences in plasma

fibrinogen, cholesterol, or triglyceride levels among seropositive and seronegative patients.

- Liuzzo G et al (N Engl J Med 1994;331:417-24.), Yarnell J et al (Circulation 1991; 83:836-44) and Xu Q, Willeit J et al (Lancet 1993;341:255-9):

Some markers of inflammation are associated with a greater risk of coronary cardiopathy or a worse prognosis, such as C reactive protein, white blood cell count, plasma fibrinogen or the presence of heat shock proteins (hsp).

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RELATION BETWEEN H. PYLORI INFECTION AND CORONARY ARTERY DISEASE

The seroprevalence of H. pylori and markers of inflammatory processes:

- Patel P et al (BMJ 1995;311:711-4): Comparison of patients seropositive for H. pylori with

seronegative patients: found a significant elevation in the white blood cell count..

- Birnie D et al (Eur Heart J 1998;19:387-94): Detected an hsp increase 60/65; and the elevation of C

reactive protein has been associated with a worse prognosis in patients with unstable angina or recent myocardial infarction.

- Regnström J et al (J Int Med 1998;243:109-13): The association of coronary cardiopathy with TNF-α values,

but statistically significant differences have not been detected.

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RELATION BETWEEN H. PYLORI INFECTION AND CORONARY ARTERY DISEASE

Presence of H. pylori in atheromatous plaques:

(Studies have been performed using the polymerase chain reaction (PCR) to detect ADN of H. pylori in the tissues analyzed):

- Cunningham et al (Rev Esp Cardiol 2002; 55(6):652-6 ): Found the presence of H. pylori in atheromatous plaques. - Gunn M et al (Heart 2000; 84: 267-271): + The significantly higher detection of Hp DNA in considerable

number of atherosclerotic plaques in CagA-positive patients. + The H.pylori with CagA-positive may be higher virulent factor

to atherosclerotic plaques.

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Carotid atherosclerotic plaques:

Immunostaining for H pylori, original magnification 1000:

A, Immunodetection of the bacillus in subendothelial clefts.

B, Immunodetection of the bacillus in the endothelial lumina.

C, Immunodetection of ICAM-1 in the cytoplasm of endothelial cells is shown.

(http://stroke.ahajournals.org/content/32/2/385.full)

RELATION BETWEEN H. PYLORI INFECTION AND CORONARY ARTERY DISEASE

c

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RELATION BETWEEN H. PYLORI INFECTION AND CORONARY ARTERY DISEASE

Presence of H. pylori in atheromatous plaques:

- Kowalski M (J Physiol Pharmacol. 2001 Aug; 52 (1 Suppl 1):3-31):

Identification of Hp DNA in atherosclerotic plaques of patients with severe CAD supports the hypothesis that infection with H. pylori (especially CagA positive) may influence the development of atherosclerosis.

- Francesch F et al (Atherosclerosis. 2009 Feb; 202(2):535-42. Epub 2008 Jul 3):

Anti-CagA antibodies recognized antigens localized inside coronary atherosclerotic plaques in all specimens from both stable and unstable angina patients.

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RELATION BETWEEN H. PYLORI INFECTION AND CORONARY ARTERY DISEASE

Detection of Hp specific DNA in human atheromatous coronary artery plaques of patients with and without Hp

infection.

[Kowalski M: Helicobacter pylori (H. pylori) infection in coronary artery disease, Physiol Pharmacol 2001; 52 (Suppl. 1): 3-31)] .

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RELATION BETWEEN H. PYLORI INFECTION AND CORONARY ARTERY DISEASE

Mean coronary artery lumen reduction (%),

six months after PTCA with stent

in patients: - Hp-CagA (+)

(subgroup a) - Hp-CagA (-)

(subgroup b) - Hp IgG (-)

(subgroup c).

[Kowalski M: Helicobacter pylori (H. pylori) infection in coronary

artery disease, Physiol Pharmacol 2001; 52 (Suppl. 1): 3-31)] .

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PATHOGENIC MECHANISMS

Inflammatory response: - Crabtree J et al (Gut 1991; 32:1473-7), Fong I et al (J

Clin Microbiol 1997; 35:48-52), Mendall M et al (Heart 1997; 78:273-7):

Changes in some cardiovascular risks factors: coagulation and lipid factors, ↑fibrinogen, ↑C-RP, ↑TNF-α, ↑IL-6, ↑WBC (→ Prothrombotic state).

- Ernst P et al (Gastroenterology 1997; 113: S 35-42): Presence of neutrophils, T lymphocytes, plasma cells and a

response that is as much cellular as it is humural. - Ossei-Gerning N et al (Cardiovasc Res 1997; 35:120-4),

Bamford K et al (Gastroenterology 1998; 114:482-92): Specific cellular response: ↑helper-1 lymphocytes → IL-1, IL-6,

IL-8, TNF- α, interferon ɣ.

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PATHOGENIC MECHANISMS

Inflammatory response: - Kalia N et al (Gut 1997; 41:748-52):

Soluble extracts of H. pylori promote platelet aggregation in the microcirculation.

- Yamaoka Y et al (Gut 1997; 41:442-51): CagA(+) H.pylori produce a greater variety of cytokines. - Abdelmouttaleb et al (Am Heart J 1999; 137: 346-351),

Gasbarrini et al (Ital J Gastroenterol Hepatol 1998; 30: 115-118 ) and Stone

et al (Digest Liver Dis 2000; 32: 62-64 ): Reported that the host immune response to the bacteria colonizing

the stomach may play an important role in the pathogenesis of vascular disorders, probably through the action of various vasoactive substances, such as cytokines, eicosanoids and others.

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PATHOGENIC MECHANISMS

(http://gut.bmj.com/content/45/suppl_1/I9/F1.large.jpg)

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PATHOGENIC MECHANISMS

Modification of blood lipids: - Ellis R et al (J Med Micriobiol 1997; 46:535-9),

Niemelä S et al (Heart 1996;75:573-5: H.pylori infection induces:

+↑cholesterol and triglyceride levels. +↓ HDL cholesterol.

Crossed reactivity with anti-hsp antibodies:

- Birnie D et al (Eur Heart J 1998; 19:387-94):

H. pylori produces anti-heat shock protein (60 kDa) similar to human 60 kDa hsp expressed by the endothelium.

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PATHOGENIC MECHANISMS

(J J Y Sung, J E Sanderson: Hyperhomocysteinaemia, Helicobacter pylon, and coronary heart disease, Heart 1996;76:305-307).

Hyperhomocysteinemia:

- Clarke R et al (N Engl J Med 1991; 324:1149-55), Bunout B et al (Med Chil 1998; 126:905-10), Markle H (Med Hypotheses 1997; 49:289-92):

H. pylori infection → ↓ absorption vitamin B12 and folate → hyperhomocysteinemia.

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PATHOGENIC MECHANISMS

Formation of oxidants: Ellis R et al ( J Med Micriobiol 1997; 46:535-9): H. pylori →↓ antioxidants → lipid peroxidation →

atherogenesis.

Socio-economic level: Nilsson P et al (Scand J Soc Med 1995;23:3-8),

Mendall M et al (Lancet 1992;339:896-7): + A greater prevalence of coronary cardiopathy and

cardiovascular events in people at a lower socio-economic levels.

+ Hp Infected patients is in socio-economic level lower than in Hp non-infected patients.

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TREATMENT

(N Engl J Med, Vol. 347, No. 15 · October 10, 2002 · www.nejm.org)

Eradication treatment

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TREATMENTRegimens recommended for eradication of H.pylori infection.Drug Dose

Triple therapy: 1. Bismuth subsalicylate (Pepto-Bismol) plus 2 tablets qid Metronidazole plus 250 mg qid Tetracycline (a) 500 mg qid 2. Ranitidine bismuth citrate plus 400 mg bid Tetracycline plus 500 mg bid Clarithromycin or metronidazole 500 mg bid 3. Omeprazol (lansoprazole) 20 mg (30 mg) daily Clarithromycin plus 250 or 500 mg bid Metronidazole (b) or 500 mg bid Amoxicillin (c ) 1000 mg bid

Quadruple therapy Omeprazole (lansoprazole) 20 mg (30 mg) daily Bismuth subsalicylate (Pepto-Bismol) 2 tablets qid Metronidazole 250 mg qid Tetracycline 500 mg qid

(a) : Alternative: use prepacked Helidac. (b) : Alternative: use prepacked Prevpac. (c) : Use either metronidazole or amoxicilline, not both. Pepto-Bismol: 525 mg (tablet). (Harrison’ s Principles of internal medicine, 17 th edition, 2008, page 1863 ).

Eradication treatment

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TREATMENTSubstance Evidence Effect

Vitamin C in vitro; in vivo(gerbils; humans)

↓ H. pylori

α-Linolenic, Linoleic, γ-Linolenic, Eicosapentaenoic acids

in vitro; in vivo (humans – fish oil andblack currant seed oil)

↓ H. pylori

Lactobacilli in vitro; in vivo (mice)in vivo (humans)

↓ H. pylori↓ antibiotic side effects↑ antibiotic effects

Mastic Gum in vitroin vivo (humans)

↓ H. pylori↑ ulcer healing

Garlic in vitroin vivo (humans)

↓ H. pylorino results

Berberine in vitro;in vivo (humans)

↓ H. pylori

Flavonoids (various) in vitro; in vivo ↓H. pylori

(Alan R. Gaby, MD: Alternative Medicine Review Volume 6, Number 4 2001).

Potential Alternative Treatments for H. pylori

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TREATMENT

(G. Lester Tarbutton et al: The Journal of applied research, vol. 7, No. 1, 2007).

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TREATMENT

The STAMINA trial (South Thames Trial of Antibiotics in Myocardial Infarction and Unstable Angina)

(n=325, addressed both C pneumoniae and H pylori).

- Multiple drug therapy using amoxicillin for H pylori and azithromycin for C pneumoniae, both combined with metronidazole and omeprazole, were found to reduce inflammatory markers. This included C-reactive protein (P=0.03) and fibrinogen (P=0.06).

- At 12 weeks of follow up there was a 36% decrease (P=0.02) in all end points (cardiac death, revascularization, and readmission).

- At 1 year there continued to be a significant reduction in end points of cardiac death or readmission with ACS.

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TREATMENT- Kowalski M (J Physiol Pharmacol 2001; 52

(Suppl. 1): 3-31): + Diameter of the coronary artery lumen six months after

PTCA was significantly different between the patients after the Hp eradication therapy and those without such therapy.

+ The mean reduction in arterial lumen in Hp-eradicated patients was about 22%, whereas in those non-eradicated about 41% and this difference was statistically significant.

- Kowalski M, Konturek PC (Digest Liver Dis 2001; 33: 222-229):

The plasma proinflammatory cytokines:TNF-α, IL-1ß and IL-8, were significantly attenuated after Hp eradication in patients with PTCA suggests that the elimination of the inflammation could contribute to the decline in restenosis mechanism.

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TREATMENT

- Yusuf SW et al (Acta Cardiol 2002; 57: 317-322 ):

The plasma levels of fibrinogen was significantly reduced after eradication.

- Konturek PC et al (J Physiol Pharmacol 1999; 50: 695-710):

The plasma levels of fibrinogen, IL-8 and LDL-cholesterol were significantly declined after eradication, .

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TREATMENT Prophylactic vaccination: - Several key bacterial factors have been identified: urease, vacuolating cytotoxin, cytotoxin-associated antigen

(cag), the pathogenicity island, neutrophil-activating protein…

- These proteins, in their native or recombinant forms, have been shown to confer protection against H. pylori in animal models.

- Nevertheless, a number of clinical trials (in healthy volunteers have been used urease by oral) give limited results.

- Recently, a vaccine (mixture of H. pylori antigens with aluminium hydroxide as an adjuvant) following intramuscular administration in H. pylori -negative volunteers was reported to be highly immunogenic.

- Data show that vaccination against H. pylori is still feasible. More researches are required to have effective vaccine may be used in the future.

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CONCLUSION

1. H. pylori is a causal agent of several gastrointestinal diseases and has also been implicated in coronary artery disease (CAD).

2. Several mechanisms are proposed for the role of H. pylori in CAD: - H. pylori may act directly on atherosclerotic plaques, because studies

have found its DNA in arterial plaque. - H. pylori causes in indirect effects to chronic inflammation whereby raises

cytokine levels in the bloodstream, thus it serves as a trigger of the inflammatory cascade.

- H. pylori may induce platelet aggregation, and thereby play a role in the acute phase of CAD.

- Certain virulent strains of H. pylori (CagA positivity) may provoke an intense immune response and precipitate coronary events.

3. Eradication therapy: - Reduce inflammatory markers: C-reactive protein, fibrinogen, LDL-

cholesterol, cytokines: TNF-α, IL-1ß and IL-8… - Reduce in arterial lumen loss and in all end points (cardiac death,

revascularization, and readmission). 4. Vaccines against H. pylori have still been researching to fulfil. 5. In the present, because of the number of studies still limit, to confirm

certainly the association between Hp infection and CAD, requires further studies with a large group of patients.

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CONCLUSION

Prediction from Paul Ewald:

” Throughout history most people have died of infectious disease, and most people continue to die of infectious disease”. Microbiologist Paul

Ewald