Association between Helicobacter pylori infection and angiographically demonstrated coronary artery disease: A meta-analysis

2024 Guidelines of the Taiwan Society of Cardiology on the Primary Prevention of Atherosclerotic Cardiovascular Disease --- Part I

Atherosclerotic cardiovascular disease (ASCVD) is one of the leading causes of death worldwide and in Taiwan. It is highly prevalent and has a tremendous impact on global health. Therefore, the Taiwan Society of Cardiology developed these best-evidence preventive guidelines for decision-making in clinical practice involving aspects of primordial prevention including national policies, promotion of health education, primary prevention of clinical risk factors, and management and control of clinical risk factors. These guidelines cover the full spectrum of ASCVD, including chronic coronary syndrome, acute coronary syndrome, cerebrovascular disease, peripheral artery disease, and aortic aneurysm. In order to enhance medical education and health promotion not only for physicians but also for the general public, we propose a slogan (2H2L) for the primary prevention of ASCVD on the basis of the essential role of healthy dietary pattern and lifestyles: "Healthy Diet and Healthy Lifestyles to Help Your Life and Save Your Lives". We also propose an acronym of the modifiable risk factors/enhancers and relevant strategies to facilitate memory: " ABC2D2EFG-I'M2 ACE": Adiposity, Blood pressure, Cholesterol and Cigarette smoking, Diabetes mellitus and Dietary pattern, Exercise, Frailty, Gout/hyperuricemia, Inflammation/infection, Metabolic syndrome and Metabolic dysfunction-associated fatty liver disease, Atmosphere (environment), Chronic kidney disease, and Easy life (sleep well and no stress). Some imaging studies can be risk enhancers. Some risk factors/clinical conditions are deemed to be preventable, and healthy dietary pattern, physical activity, and body weight control remain the cornerstone of the preventive strategy.

Prevalence of Helicobacter pylori Infection in Bariatric Surgery Patients

OBJECTIVE

To determine the rate of histology-proven Helicobacter pylori (HP) infection in patients undergoing bariatric surgery and to identify risk factors for HP infection.

METHODS

In a retrospective analysis, patients who underwent bariatric surgery with gastric resection in a single hospital between January 2004 and January 2019 were analyzed. For each patient, a surgical specimen was submitted for anatomopathological examination and analyzed for gastritis or other anomalies. When gastritis was present, HP infection was confirmed by the identification of curvilinear bacilli in conventional histology or by specific immunohistochemical detection of HP antigen.

RESULTS

A total of 6388 specimens were available for review (4365 women, 2023 men) with a mean age of 44.9 ± 11.2 years and a mean body mass index (BMI) of 49.3 ± 8.2 kg/m2. Histology-proven HP infection rate was 6.3% (n = 405). There was no significant difference in sex, BMI, and body weight between HP + and HP - patients. Logistic regressions identified age as a risk factor for HP infection in this population (OR 1.02, p < 0.0001, CI 95% 1.01-1.03 for every 1-year increase, OR 1.26, p < 0.0001, CI 95% 1.14-1.40 for every 10-year increase).

CONCLUSIONS

The rate of histology-proven HP infection is low in patients with severe obesity who present for bariatric surgery and is associated with age.

Helicobacter pylori and cardiovascular risk: Only a dead Helicobacter is a good Helicobacter?

OBJECTIVES

Helicobacter pylori (H. pylori) and cardiovascular (CV) disease share common symptoms and underlie many general medical complaints. Preliminary studies suggest an association between H. pylori positivity and CV risk, and gastroenterological guidelines recommend eradication of H. pylori in patients with manifest atherosclerosis. Therefore, the aim of this study was to examine the reciprocal association of H. pylori positivity and CV risk for their independence of shared risk factors.

METHODS

We included 3284 asymptomatic participants of a colorectal cancer screening cohort who were offered and underwent upper gastrointestinal endoscopy. We calculated the 10-year risk for a CV event using the novel SCORE2 for each patient. We evaluated the association between H. pylori positivity and CV risk assessed by SCORE2 using both multilevel logistic and linear regression. We adjusted for age, sex and the concomitant diagnosis of metabolic syndrome. Lastly, we assessed the association between H. pylori status and mortality using proportional hazard Cox regression.

RESULTS

In total, 2659 patients were H. pylori negative and 625 H. pylori positive. Helicobacter pylori positivity was associated with SCORE2 and remained so (r = .33; 95% CI 0.09-0.57; p = .006) after adjustment for age, sex, and the diagnosis of metabolic syndrome. Also, SCORE2 was associated with higher odds for H. pylori positivity (aOR 1.03 95% CI 1.01-1.05; p = .02) even after multivariable adjustment. Helicobacter pylori positivity was associated with neither CV (HR 0.60 95% CI 0.14-2.63; p = .50) nor all-cause (HR 1.20 95% CI 0.77-1.87; p = .43) mortality during a median follow-up of 9 years.

CONCLUSIONS

In our study, H. pylori positivity and CV risk were independently associated. This did not translate into a dissimilar CV mortality between H. pylori positive and H. pylori negative patients. However, the overwhelming majority of our patients underwent H. pylori eradication. We, therefore, think that H. pylori eradication is at least safe from a cardiovascular perspective and warranted from gastrointestinal standpoint.

Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report

Helicobacter pyloriInfection is formally recognised as an infectious disease, an entity that is now included in the International Classification of Diseases 11th Revision. This in principle leads to the recommendation that all infected patients should receive treatment. In the context of the wide clinical spectrum associated with Helicobacter pylori gastritis, specific issues persist and require regular updates for optimised management.The identification of distinct clinical scenarios, proper testing and adoption of effective strategies for prevention of gastric cancer and other complications are addressed. H. pylori treatment is challenged by the continuously rising antibiotic resistance and demands for susceptibility testing with consideration of novel molecular technologies and careful selection of first line and rescue therapies. The role of H. pylori and antibiotic therapies and their impact on the gut microbiota are also considered.Progress made in the management of H. pylori infection is covered in the present sixth edition of the Maastricht/Florence 2021 Consensus Report, key aspects related to the clinical role of H. pylori infection were re-evaluated and updated. Forty-one experts from 29 countries representing a global community, examined the new data related to H. pylori infection in five working groups: (1) indications/associations, (2) diagnosis, (3) treatment, (4) prevention/gastric cancer and (5) H. pylori and the gut microbiota. The results of the individual working groups were presented for a final consensus voting that included all participants. Recommendations are provided on the basis of the best available evidence and relevance to the management of H. pylori infection in various clinical fields.

Helicobacter pylori: an up-to-date overview on the virulence and pathogenesis mechanisms

Helicobacter pylori is an organism associated with ulcer disease and gastric cancer. The latter is one of the most prevalent malignancies and currently the fourth major cause of cancer-related deaths globally. The pathogen infects about 50% of the world population, and currently, no treatment ensures its total elimination. There has been an increase in our understanding of the pathophysiology and pathogenesis mechanisms of H. pylori over the years. H. pylori can induce several genetic alterations, express numerous virulence factors, and trigger diverse adaptive mechanisms during its adherence and colonization. For successful colonization and infection establishment, several effector proteins/toxins are released by the organism. Evidence is also available reporting spiral to coccoid transition as a unique tactic H. pylori uses to survive in the host's gastrointestinal tract (GIT). Thus, the virulence and pathogenicity of H. pylori are under the control of complex interplay between the virulence factors, host, and environmental factors. Expounding the role of the various virulence factors in H. pylori pathogenesis and clinical outcomes is crucial for vaccine development and in providing and developing a more effective therapeutic intervention. Here we critically reflect on H. pylori infection and delineate what is currently known about the virulence and pathogenesis mechanisms of H. pylori.

Helicobacter pylori increases the risk of carotid plaque formation: a clinical evidence

Background and aim: Since the relation between Helicobacter pylori (H. pylori) and atherosclerosis has been evidenced, we aimed to analyze whether there is a relationship between the patient's H. pylori infection and age, gender, BMI, blood lipids, and carotid plaque formation.Methods: 810 patients from January 2016 to December 2019 were enrolled in this study, and divided the subjects into H. pylori (+) group and H. pylori (-) group based on the results of UBT. To analyze whether H. pylori infection is related to gender, age, BMI, blood lipids, and neck vascular plaque formation.Results: The single-factor analysis showed that the BMI ≥ 25kg/m2, triglycerides >1.7 mmol/l, the formation of cervical plaques were significantly higher in patients infected with H. pylori in compared to normal cases. Also, multi-variant logistic regression analysis showed that H. pylori infection affects the BMI ≥ 25kg/m2 and triglycerides >1.7 mmol/l to induce vascular plaque. Also, we showed that patients with H. pylori infection are 1.424 times higher than the non-infected group to have triglycerides more elevated than 1.7mmol/l.Conclusion: In this study, we conclude that H. pylori infection is an independent risk factor for higher BMI (>25), triglyceride (>1.7 mmol/l), and neck vascular plaque formation. The multi-variant analysis showed that patients with H. pylori infection are prone to have higher BMI, triglycerides, and neck vascular plaque formation over 1.4-times higher in non-infected individuals.KEY MESSAGESH. pylori infection is an independent risk factor for higher BMI, triglyceride, and neck vascular plaque formation.H. pylori can accelerate vascular plaque formation through increasing BMI and triglyceride.

Association between helicobacter pylori infection and subclinical atherosclerosis: A systematic review and meta-analysis

BACKGROUND

The relationship between Helicobacter pylori (H. pylori) infection and subclinical atherosclerosis has been confirmed, but these conclusions are still controversial. Therefore, we have performed a systematic review and meta-analysis to assess the association between H. pylori infection and subclinical atherosclerosis.

METHODS

Databases including PubMed, Embase, Web of Science were searched for the articles on the association of carotid intima-media thickness or pulse wave velocity with H. pylori infection published up to January 1, 2020. Stata 12.0 was used to calculate standardized mean difference (SMD) and 95% confidence interval (95% CI); the I2 test was used to evaluate heterogeneity between studies and sensitivity analysis and subgroup analysis were used to explore the source of heterogeneity. Funnel plot, Begg test, and Egger test were used to estimate publication bias.

RESULTS

Data were extracted from 18 studies involving 6776 subjects with H. pylori positive and 7794 with H. pylori negative. H. pylori positive subjects is significantly associated with increased subclinical atherosclerosis as determined by carotid intima-media thickness (SMD: 0.376 mm; 95% CI: 0.178, 0.574; P < .001, I2 = 90.6%), pulse wave velocity (SMD: 0.320 m/s; 95% CI: 0.242, 0.398; P < .001, I2 = 52.6%), compared with H. pylori negative. Similar results were observed when subgroups analysis were stratified according to age, male ratio, geographical location, H. pylori diagnosis, and study design. Sensitivity analyses showed that our results were robust. The Begg test or Egger test showed no significant publication bias (all P > .05).

CONCLUSIONS

This meta-analysis confirmed a significant association between H. pylori and subclinical atherosclerosis, which will help H. pylori patients to establish effective strategies for the prevention and control of cardiovascular events.

Helicobacter pylori in Human Stomach: The Inconsistencies in Clinical Outcomes and the Probable Causes

Pathogenic potentials of the gastric pathogen, Helicobacter pylori, have been proposed, evaluated, and confirmed by many laboratories for nearly 4 decades since its serendipitous discovery in 1983 by Barry James Marshall and John Robin Warren. Helicobacter pylori is the first bacterium to be categorized as a definite carcinogen by the International Agency for Research on Cancer (IARC) of the World Health Organization (WHO). Half of the world’s population carries H. pylori, which may be responsible for severe gastric diseases like peptic ulcer and gastric cancer. These two gastric diseases take more than a million lives every year. However, the role of H. pylori as sole pathogen in gastric diseases is heavily debated and remained controversial. It is still not convincingly understood, why most (80–90%) H. pylori infected individuals remain asymptomatic, while some (10–20%) develop such severe gastric diseases. Moreover, several reports indicated that colonization of H. pylori has positive and negative associations with several other gastrointestinal (GI) and non-GI diseases. In this review, we have discussed the state of the art knowledge on “H. pylori factors” and several “other factors,” which have been claimed to have links with severe gastric and duodenal diseases. We conclude that H. pylori infection alone does not satisfy the “necessary and sufficient” condition for developing aggressive clinical outcomes. Rather, the cumulative effect of a number of factors like the virulence proteins of H. pylori, local geography and climate, genetic background and immunity of the host, gastric and intestinal microbiota, and dietary habit and history of medicine usage together determine whether the H. pylori infected person will remain asymptomatic or will develop one of the severe gastric diseases.

Anti-Glycan Autoantibodies Induced by Helicobacter pylori as a Potential Risk Factor for Myocardial Infarction

A number of epidemiological studies have evaluated the potential association between H. pylori and cardiovascular disease, but with contrasting results. We have previously shown that Helicobacter pylori infection is able to induce in mice and humans autoantibodies cross-reacting with histo–blood group Lewis antigens, expressed in different organs and in plasma glycoproteins and glycolipids. The aim of this study was to assess whether immunization of animals with H. pylori might induce myocardial histopathological changes. We have retrospectively examined, in detail, the histology of archived organs from mice and rabbits immunized with H. pylori in our previous studies. Human sera and cross-reacting monoclonal antibodies were also tested against bacterial preparations and tissue sections. Areas of myocardial necrosis, associated with coronary thrombotic occlusion, were found in 5 of 20 mice and 2 of 5 rabbits previously immunized with suspensions of H. pylori. No similar lesions were found in control animals, suggesting a causal link with H. pylori immunization. The animals bearing myocardial lesions had not been infected but only immunized months earlier with parenteral injections of dead H. pylori cells. This strongly suggests that immunization, by itself, might play a causative role. We propose that the cross-reactive autoimmune response induced by H. pylori could promote thrombotic occlusion through direct endothelial damage or by perturbing the coagulation process.

Helicobacter pylori infection selectively increases the risk for carotid atherosclerosis in young males

BACKGROUND AND AIMS

Atherosclerosis is an important contributing factor to cardiovascular mortality. The role of Helicobacter pylori (H. pylori) infection in atherosclerosis is inconsistent and sometimes controversial. The present study aimed to determine if H. pylori infection is associated with carotid atherosclerosis.

METHODS

17,613 males and females with both carotid ultrasonic examination and ¹³C-urea breath test for H. pylori infection were screened by a major Chinese university hospital from March 2012 to March 2017 for the study. Baseline demographics, cardiac risk factors, and laboratory studies were obtained. After exclusion for pre-specified conditions, 12,836 individuals were included in the analysis, including 8157 men (63.5%) and 4679 women (36.5%). Analysis was also made for 5-year follow-up data of 1216 subjects (869 males and 347 females) with and without H. pylori infection for development and progression of carotid atherosclerosis.

RESULTS

After adjusting for age, sex, body mass index, lipid profile, hypertension, renal function, diabetes mellitus, and smoking, H. pylori infection was found as an independent risk factor for carotid atherosclerosis in males under 50 years, but not in older males or females (odds ratio 1.229, 95% CI 1.054-1.434, p = 0.009). Follow-up data analysis showed that the incidence of carotid atherosclerosis from no atherosclerosis to detectable lesions was significantly higher in young males with persistent H. pylori infection than those without H. pylori infection (p = 0.028) after 3 years.

CONCLUSIONS

These data suggest that H. pylori infection might be an important risk factor for carotid atherosclerosis in young Chinese males under 50.

Helicobacter pylori and cardiovascular disease: update 2019

Many studies have been performed concerning the potential role of Helicobacter pylori (H. pylori) in different extra-gastric diseases. Ischemic heart disease (IHD) remains the leading cause of mortality in developed countries. The traditional cardiovascular risk factors could not predict all cases of IHD. Hence, the scientists explore other potential etiologic factors, especially infections. H. pylori infection has been suspected to have a role in the pathogenesis of atherosclerosis. However, after 25 years from the first description, the role of the bacterium in the pathogenesis of IHD remains controversial and enigmatic. Since H. pylori infection is persistent and stimulates both a local and a systemic immune response that could cause significant changes in the markers of inflammation like cytokines, C-reactive protein, heat shock protein, fibrinogen, triglycerides, high density lipoprotein, it has been supposed that the outcomes of this process are atherosclerosis and a prothrombotic state which eventually leads to IHD. Alternative pathogenic mechanisms have been hypothesized, including the occurrence of molecular antigenicity. This hypothesis supposed that H. pylori could provoke autoimmunity as a result of molecular mimicry. The eradication of H. pylori infection as cardiovascular prevention strategy has been the object of some studies. However, the results are of difficult interpretation. Further studies, especially with a cohort and interventional design, have to be performed to reveal the potential relationship between H. pylori and IHD.

Helicobacter pylori Seropositivity: Prevalence, Associations, and the Impact on Incident Metabolic Diseases/Risk Factors in the Population-Based KORA Study

Introduction: Helicobacter pylori (H. pylori) is a common infection and known risk factor for gastric cancer. We assessed cross-sectional and longitudinal associations to study the impact of H. pylori seropositivity on metabolic diseases. Methods: Helicobacter pylori seropositivity in serum samples of the KORA study was analyzed by multiplex serology. We calculated sex-specific prevalence of H. pylori seropositivity for the year 2007 based on the first follow-up survey (termed F4) of the KORA study S4. We identified factors associated with H. pylori seropositivity in the F4 survey. Further, we assessed relative risks of incident metabolic diseases/risk factors at the time of the second follow-up survey of S4 (termed FF4) and H. pylori seropositivity at the F4 survey as a determinant. Models were adjusted for age, sex, overweight status, physical activity, smoking status, education level, alcohol intake, and other metabolic diseases. Results: Based on 3,037 persons aged 32 to 82 years, the H. pylori prevalence for 2007 was 30.2% in men (n = 1,465) and 28.1% in women (n = 1,572). Increasing age, current smoking, low education and no alcohol intake were significantly associated with H. pylori seropositivity in the F4 survey. However, no association between H. pylori seropositivity and BMI, metabolic diseases (type 2 diabetes, hypertension and dyslipidemia, gout or increased uric acid) and gastrointestinal diseases (gastritis, inflammatory bowel disease, and gastric or duodenal ulcer) was observed. No significant associations between H. pylori seropositivity and one of the five investigated incident metabolic diseases/risk factors were detected in the longitudinal analysis. Conclusion: We identified associations between age, smoking, education and alcohol intake and H. pylori seropositivity but no impact of H. pylori seropositivity on incident metabolic diseases/risk factors.

Helicobacter pylori infection and prevalence of stroke

BACKGROUND

Helicobacter pylori causes peptic ulcer disease; however, conflicting evidence exists regarding its role in extragastric conditions. We aimed to examine associations of H pylori infection and peptic ulcer disease with stroke.

METHODS

A cross-sectional study was undertaken using data of 147 936 individuals aged 25-95 years who underwent the urea breath test during 2002-2012, based on the computerized database of the second largest health maintenance organization in Israel. Logistic regression models were fitted to control for potential confounders.

RESULTS

Overall, 1397 (0.9%) patients had stroke and 76 965 (52.0%) had a H pylori positive test. The likelihood of prevalent stroke increased in relation to H pylori infection: adjusted odds ratio (aOR) 1.16 (95% confidence intervals [CI]: 1.04-1.29), gastric ulcer: aOR 1.50 (95% CI: 1.18-1.91), and duodenal ulcer: aOR 1.25 (95% CI: 1.07-1.46).

CONCLUSIONS

The results support the premise that stroke may be associated with a history of H pylori infection.

Helicobacter pylori and extragastric diseases

Many studies have been performed in the last year concerning the potential role of Helicobacter pylori in different extragastric diseases, reinforcing the idea that specific microorganisms may cause diseases even far from the primary site of infection. While the role of H. pylori on idiopathic thrombocytopenic purpura, sideropenic anemia, and vitamin B12 deficiency has been well established, there is a growing interest in other conditions, such as cardiovascular, neurologic, dermatologic, obstetric, immunologic, and metabolic diseases. Concerning neurologic diseases, there is a great interest in cognitive impairment and neurodegeneration. The aim of this review was to summarize the results of the most relevant studies published over the last year on this fascinating topic.

H. pylori infection and extra-gastroduodenal diseases

Helicobacter pylori infection is the principal cause of peptic ulcer disease, gastric adenocarcinoma and gastric mucosa-associated lymphoid tissue lymphoma. Recent studies have shown that it may interfere with many biological processes and determine or influence the occurrence of many diseases outside the stomach. Currently, the role of H. pylori in idiopathic thrombocytopenic purpura and iron deficiency anemia is well documented. Emerging evidence suggests that it may also contribute to vitamin B12 deficiency, insulin resistance, metabolic syndrome, diabetes mellitus and non-alcoholic liver disease. Additionally, it may increase the risk of acute coronary syndrome, cerebrovascular disease, neurodegenerative disease and other miscellaneous disorders. Different pathogenic mechanisms have been hypothesized, including the occurrence of molecular mimicry and the induction of a low-grade inflammation. This review summarizes the results of the most relevant studies on the extra-gastroduodenal manifestations of H. pylori infection.

Current Helicobacter pylori infection is significantly associated with subclinical coronary atherosclerosis in healthy subjects: A cross-sectional study

Helicobacter pylori is a gastrointestinal pathogen known to be associated with cardiovascular disease (CVD). However, most analyses about the effect of H. pylori infection have been done in patients with a history of CVD but not in healthy subjects. We evaluated the association between H. pylori infection and subclinical atherosclerosis by using cardiac multidetector computed tomography (MDCT) in healthy subjects without previous CVD. From December 2007 to February 2014, 463 subjects who underwent the rapid urease test (CLO test), pulse-wave velocity (PWV) measurement, and MDCT for a self-referred health check-up were enrolled to this study. Helicobacter pylori infection was defined on the basis of CLO test positivity on endoscopic gastric biopsy. Significant coronary artery stenosis was defined as ≥50% stenosis in any of the major epicardial coronary vessel on MDCT. The CLO-positive subjects had a lower high-density lipoprotein-cholesterol (HDL-cholesterol) level compared to the CLO-negative subjects. The incidence of significant coronary stenosis was higher in the CLO-positive group (7.6% vs. 2.9%, P = 0.01). Furthermore, the number of subjects with coronary artery calcium score >0 and log{(number of segments with plaque)+1} were also significantly higher in the CLO-positive group. However, there was no statistical difference in the number of subjects with coronary artery calcium score >100, the prevalence of any plaque nor the plaque characteristics (calcified, mixed, or soft). Pulse-wave velocity (PWV) was neither associated with CLO test positivity. The CLO-positive group was 3-fold more likely to have significant coronary artery stenosis even after adjusting for confounding factors (adjusted odds ratio 2.813, 95% confidence interval 1.051–7.528, P = 0.04). In a healthy population, current H. pylori infection was associated with subclinical but significant coronary artery stenosis. The causal relationship between H. pylori infection and subclinical atherosclerosis in a “healthy” population remains to be investigated in the future.

Helicobacter pylori infection and extragastric diseases in 2017

The huge variety of extragastric diseases linked to Helicobacter pylori infection is widely known, and new studies are conducted every year on this topic. Neurological disorders and metabolic syndrome are some of the main issues debated in the most recent literature. Articles on the association of H. pylori with skin diseases, inflammatory bowel diseases, immunologic impairment, kidney dysfunction, allergic asthma, and respiratory diseases have been published as well. In this perspective, eradication therapy for this infection could become a mandatory measure in prevention strategy.