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Beyond the gut: a comprehensive meta-analysis on Helicobacter pylori infection and cardiovascular complications

Annals of Clinical Microbiology and Antimicrobials volume 24, Article number: 18 (2025) Cite this article

Abstract

Background

Helicobacter pylori (H. pylori) is known to induce chronic inflammatory conditions, and interactions between the host immune system and pathogen have diverted attention toward investigating its correlation with extra-gastrointestinal disorders.

Objective

The present study aimed to assess the rate of H. pylori infection in cardiovascular disease (CVD) through a systematic review and meta-analysis.

Methods

We conducted a large-scale meta-analysis to determine the prevalence rates of H. pylori infection in vascular diseases. Articles from PubMed/Medline, Web of Science, and Embase databases published between 2000 and 2023 were included for analysis. We used multiple independent observers to extract data, calculated the pooled frequency of H. pylori in vascular diseases using a random effect model, and reported the results as a weighted average based on the study population. The main outcome measures were presented with 95% confidence intervals (CI).

Results

In 87 included studies, the prevalence of H. pylori infection in vascular diseases was 56.7% worldwide. 14.25% of H. pylori isolates harbored the cagA gene. The predominant vascular complication was coronary artery disease (CAD) (31.07%), primarily documented in Europe. This meta-analysis revealed a declining emphasis on studying the association of H. pylori infection with vascular disease in recent times.

Conclusion

According to this meta-analysis, H. pylori infection has a high frequency in CVD and may increase the risk of vascular diseases. However, further research is required, particularly in nations with limited data.

Introduction

Cardiovascular disease (CVD) is the leading cause of global mortality and morbidity [1]. The common risk factors of CVD are hypertension, old age, physical inactivity, diabetes mellitus, dyslipidemia, obesity, and smoking [2]. Moreover, inflammatory factors and oxidative stress are among the novel risk factors that may be useful for CVD prevention [3]. Helicobacter pylori (H. pylori) infection is a risk factor for developing coronary heart disease, arrhythmia, and acute myocardial infarction [4]. The inflammatory responses triggered by the H. pylori infection are the main underlying causes of cardiovascular complications [5]. H. pylori strains possess a cytotoxin-associated gene A (cagA) is more virulent and more strongly related to the risk of coronary atherosclerosis [6]. These strains increase the activity of endothelial cycloxygenase-1 and −2. Also, cagA-induced inflammation may promote the release of cytokines (including IL-8), tumor necrosis factor- α (TNF-α), and T and B lymphocytes, thereby causing cardiac diseases [5]. Particularly, an autoimmune reaction might be proposed that involves cross-reactivity between anti-cagA antibodies and vascular wall antigens, implying that these antibodies may contribute to the activation of inflammatory cells within atherosclerotic lesions. H. pylori carries the heat shock protein-60 (HSP60), which is identical to an arterial cell surface protein found in endothelial cells [7, 8]. Therefore, an immune response to H. pylori may induce immune cross-reaction between human and bacterial HSP60, which in turn leads to an autoimmune reaction and local inflammation of the artery.

Chronic inflammatory response. This gram-negative bacilli infection increases fibrinogen, blood leukocytes, and homocysteine levels, stimulates the release of C-reactive protein (CRP), induces hypercoagulability, and increases the production of proinflammatory inflammatory metabolites. An increase in cytokines (IL-1, IL-6, and IL-8) alters blood vessel motility and induces endothelial dysfunction, resulting in the beginning, progression, and consequences of atherosclerotic plaque formation, thus raising the risk of heart attack [9, 10].

Furthermore, H. pylori infection is linked to dyslipidemia. Pro-inflammatory cytokines, particularly TNF-α, can block lipoprotein lipase and increase free radical generation. Patients with H. pylori infection have lipid profile abnormalities, including low HDL cholesterol and high total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglyceride levels. Early events in atherosclerosis include increased transcytosis of low-LDL across the endothelium and the oxidation of LDL deposited within the subendothelial region [11]. Furthermore, oxidised LDL stimulates IL-8 production, which is greatly increased by H. pylori infection, resulting in increased recruitment of T lymphocytes and smooth muscle cells, leading to atherosclerotic plaques. Studies have discovered bacterial DNA in atherosclerotic plaques, where it generates patches of infection that contribute to heart disease [12].

This systematic review and meta-analysis aimed to determine the worldwide prevalence of H. pylori infection and its association with CVD risk, given its importance.

Methods

Search strategy

A thorough, systematic search for appropriate papers published in PubMed/Medline, Web of Science, and Embase was done. All research published in English between 1998 and 2023 were reviewed.

The search approach included the following terms: “Helicobacter pylori” OR “H. pylori” AND “cardiovascular disease” OR “coronary heart disease” OR “coronary artery disease” OR “myocardial infarction” OR “ischemic heart disease” OR “atherosclerotic stroke” OR “CHD” OR “CVD” OR “CAD”. We utilized MeSH terms while searching PubMed/Medline and Embase. This method was independently examined by two distinct investigators (BH and FS). The PICO method was used to create the inclusion and exclusion criteria for study selection. Therefore, we assessed the data on P (Patient, Population, or Problem) = patients with CVD, I (Intervention or exposure) = H. pylori infection, and C ( Comparison) = not available, and O (Outcome) = Relationship between H. pylori infection and risk of CVD.

All clinical studies investigating the presence of H. pylori infection in patients with coronary artery disease (CAD) were included, except for articles that reported only the prevalence of H. pylori or the prevalence of CAD alone, duplicated articles, abstracts presented at conferences, reviews, book chapters, case reports, case series, and meta-analyses. Relevant prevalence studies were considered. In the following phase, two investigators (KK, YA) reviewed the titles and abstracts of all selected publications.

Data extraction

The first author's name, the year of publication, the type of study, the nation where the study was done, the age and gender of the patients, the number of patients with CAD, the number of patients H. pylori, and the type of CAD were extracted from all eligible publications and entered into a data extraction form. To eliminate bias, two writers separately recorded the data (SY, SHY). The disagreement was addressed by discussion amongst the authors (MD, AB).

Quality assessment

The critical appraisal checklist provided by the Joanna Briggs Institute (JBI) was used to perform a quality assessment of the studies [13].

Statistical analyses

Statistical analyses were conducted using Comprehensive meta-analysis (CMA) software (version 2.0, Biostat, USA). The pooled frequency with 95% confidence intervals (CI) was calculated using the random effect model. Cochran’s Q and the I2 statistic were used to analyse heterogeneity between studies. To investigate heterogeneity, subgroup analyses stratified by disease type were conducted. Begg's test was used to examine publication bias statistically (a P value of less than 0.05 indicated statistically significant publication bias).

Results

Characteristics of included studies

Overall, 2098 citations were found during the first database searches. Our data was gathered from three databases, and some duplicate research were included. Following the removal of 986 duplicates, there were 1112 non-duplicate studies. After reviewing the titles and abstracts, we selected 745 studies that were not relevant. In addition, 280 irrelevant items were removed throughout the full-text screening process. The final analysis included 87 studies (see Table 1). Figure 1 depicts the rationale for eliminating papers at various levels of the evaluation. According to published sources, males outnumbered females by 6.7 times. Table 2 shows that the majority of the studies were published between 1998 and 2006 (56.3%), 2007 to 2015 (27.6%), and 2016 to 2023 (16.1%). Most of the articles included in the present study were published in Europe (60.9%), and Italy had the most reported articles in this continent (28.3%). Figure 2 shows the number of articles published each year.

Table 1 Characteristics of the included studies
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Fig. 1
figure 1

Flow chart of study selection for inclusion in the systematic review

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Table 2 Prevalence of published studies reporting H. pylori in CVD in different time periods worldwide
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Fig. 2
figure 2

Global CVD rates among patients with H. pylori during 1998–2023

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Prevalence of H. pylori infection in CVD

The estimated rate of H. pylori in individuals with CVD was 56.7% [95% confidence interval (CI) 53.7–59.6, I2: 89.9%]. (Fig. 3). Figures 4 and 5 show the forest and funnel plots, respectively. Africa had the greatest frequency of H. pylori infection in CVD (64%), followed by Asia (61.6%), America (55.3%), and Europe (53.8%) (Figs. 6–8), there were no reports from Oceania.

Fig. 3
figure 3

Frequency of H. pylori among patients with CVD worldwide

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Fig. 4
figure 4

forest plot of the meta-analysis on the prevalence of H. pylori among patients with CVD worldwide

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Fig. 5
figure 5

funnel plot of the meta-analysis on the prevalence of H. pylori among patients with CVD worldwide

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Fig. 6
figure 6

Frequency of H. pylori among patients with CVD in different continents

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Prevalence of H. pylori cagA gene in patients with vascular diseases

As indicated in Table 3, 14.25% of the 6775 H. pylori isolates had the cagA gene. The highest prevalence of this gene was seen in Europe (87.1%), with the highest frequencies found in Italy (34.7%) and England (32.8%). None of the H. pylori isolates from America included the cagA gene.

Table 3 Distribution of cagA gene among H. pylori in vascular diseases in different continent
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The most prevalent vascular disease among patients with H. pylori in different continents

The most common CVD manifestations in 6775 individuals with H. pylori infection were CAD (31.07%) and atherosclerotic stroke (22.45%), respectively. CAD was most common in Europe (43.75%), Asia (38%), Africa (5.3%), and America (2.87%). In Europe, CAD is mostly documented in Germany, Croatia, and Greece. According to published studies, atherosclerosis stroke occurred exclusively in Europe (17.07%) and Asia (5.37%). Cerebral microbleeds were the least common CVD documented in Asia (0.45%) (Table 4).

Table 4 Type of vascular diseases in H. pylori positive patients
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The most prevalent clinical source, detection methods, and underlying diseases among patients with H. pylori

According to published studies, H. pylori is mostly isolated from the serum of patients with CVD (86.77%). Following that, there was a breathing test and a gastrointestinal biopsy (7.97% and 3.64%, respectively). H. pylori was identified mostly by serological techniques (86.77%). The stool antigen test was shown to be the least commonly utilised approach for identifying H. pylori (0.41%). In addition, the most common underlying illnesses among patients infected with H. pylori were hypertension (4.8%), diabetes (2.58%), and obesity (0.13%) (Table 5).

Table 5 Characteristics of clinical source, detection methods and underlying diseases of the included studies
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Discussion

H. pylori has been reported to contribute to the development of CVD in a variety of ways, including causing inflammation, endothelial dysfunction, dyslipidemia, iron and vitamin B12 malabsorption, and elevating CRP levels [5]. Recent research have shown conflicting findings about the involvement of this bacterium in the development of vascular disorders. As a result, our study intends to offer precise statistics on the prevalence of H. pylori infection among patients with vascular disorders worldwide. In our analysis, the global prevalence of H. pylori infection among CVDs was 56.7%.

Europe has the highest incidence, followed by Asia, America, and Africa. It is worth noting that the considerable number of research conducted in Asia (31.03%) and Europe (60.92%), as opposed to America (4.59%) and Africa (3.44%), may have influenced these findings.

According to a meta-analysis published by Hooi et al., Africa has the highest incidence of H. pylori infection worldwide, whereas our findings show that the prevalence of H. pylori in individuals with vascular disease is the lowest worldwide. This issue may be attributable to the small number of studies undertaken on this continent [14].

Furthermore, the lack of eligible studies from Oceania means that there is a lack of access to prevalence statistics in this region.

Interestingly, England had the highest prevalence rate in Europe. It is important to note that all relevant studies in this country were done between 1998 and 2006. As a result, the figures obtained may not precisely represent the current prevalence rate in this country. Argentina has the lowest prevalence rate in Europe, which could be attributed to the country’s small sample size and limited number of research (see Figs. 7, 8).

Fig. 7
figure 7

forest plot of the meta-analysis on the prevalence of H. pylori among patients with CVD in different continents

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Fig. 8
figure 8

funnel plot of the meta-analysis on the prevalence of H. pylori among patients with CVD in different continents

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CagA is a surface protein that is associated with a more virulent strain of H. pylori [15]. According to Huang’s study infection with cagA positive strain leads to an increase in the risk of atherosclerosis [16]. In our investigation, the cagA gene was not commonly found in H. pylori isolates. This could be because many research have not looked at the presence of this gene. There has been no record of the cagA gene in America, hence there are no statistics on H. pylori cagA positive strains on this continent. The high incidence of H. pylori cagA positive strain in Europe may be linked to the availability of study undertaken on this topic in this region, whereas other places have minimal data available, since 90% of the studies that offered cagA statistics are related to the European countries.

Our findings demonstrated the most common type of CVD in H. pylori patients was CAD and mainly reported in Europe. Daponte-Codina et al. reported that CAD accounts for 20% of all mortality in Europe and is the most common form of CVD [17]. The high number of reports on CAD in the world is proof of the claim that H. pylori plays a significant role in causing this class of CVD. H. pylori, with the help of cagA and the type IV secretion system, causes hyperhomocysteinemia caused by malabsorption and incomplete metabolism of folate and vitamin B12, as well as molecular mimicry, leading to major changes in the lipid profile of coronary arteries and the development of CAD [5].

Atherosclerotic stroke was the second CVD diagnosed in H. pylori patients. The disease was most prevalent throughout Europe and England. Given the high number of heart attacks in England, the identification, treatment, and eradication of H. pylori can be employed as a reasonable and cost-effective method to avoid atherosclerotic strokes and myocardial infarction [6]. The lowest rate of Atherosclerotic stroke was reported in Japan. The results suggested that Japanese-style dietary patterns and characteristic Japanese food intake would contribute to reducing CVD risk [18].

Furthermore, we explored cerebrovascular disorders in the current study. Unfortunately, because of the complexity of sampling and the scarcity of samples, these disorders have far less literature than CAD. As a result, the conclusions and figures derived from their study are confusing. As a result, only two research met the criteria for inclusion in our study. Both studies were from Asia, one from Japan with 0.48% of all instances of cerebral infarction and the other from China with 0.45% of all cases of cerebral microbleeds. These findings revealed that researchers from other continents have focused on the potential link between H. pylori infection and cerebrovascular disease [7].

Serological approaches were the most commonly employed diagnostic tools in our investigation. Because of the requirement for upper endoscopy and the invasive nature of these procedures, their usage has been limited. It is crucial to highlight that utilising serological tests to diagnose H. pylori infection can have an impact on the accuracy of the results because these tests have limits in discriminating between early and late infections. According to Bordin's study, the noninvasive gold standard for detecting H. pylori infection is the urea breath test, which has a sensitivity of 96–100% and a specificity of 93–100%. In contrast, the serological test for this illness has a sensitivity of 85% and a specificity of 79% [19].

In the articles included in our study, underlying diseases have been examined as risk factors for cardiovascular diseases. Our findings demonstrated that hypertension is the most frequently occurring underlying disease among patients.

A study by Fang et al. found a significant link between H. pylori and hypertension, a key risk factor for cardiovascular disease [20]. It is important to emphasise that the low prevalence rate of hypertension in the current study can be related to the failure to examine underlying disorders in many of the selected papers. In the current investigation, H. pylori in CVD patients is primarily isolated from men. The likely reason for this is that the incidence of CVD in women is usually lower than in men. However, women have a higher mortality and worse prognosis after acute cardiovascular events [21].

Another remarkable feature is the 3.5-fold decrease in the number of reports on H. pylori in CVD worldwide between 2016 and 2023 compared to 1998–2006. Asia had the most reports in the last seven years. However, compared to 1998–2006 and 2007–2015, the number of published studies has decreased. The main thing regarding Europe is that the number of studies between 2016 and 2023 has declined by more than seven times when compared to 1998 to 2006. In the United States, reports of H. pylori in CVD were first published between 1998 and 2006. Another noteworthy discovery was that the number of publications released between 2016 and 2023 increased solely in Africa in contrast to 2007–2015. Moreover, with no publications emerging from Oceania, evaluating the progression of H. pylori infection in CVD over time in this region remains unfeasible. This study has certain drawbacks, which are as follows: First, since the frequency of the cagA gene was not explored in many researches, we could not identify a link between the presence of this gene and various forms of CVD. Second, there is minimal evidence on the relationship between H. pylori infection and underlying illnesses in CVD patients. As a result, we cannot assess the link between H. pylori infection and the development of underlying disorders. Third, a paucity of studies in diverse geographic regions, such as Oceania and Africa, limits the capacity of researchers to collect precise figures on the prevalence of H. pylori among CVD patients worldwide.

Conclusion

Our findings revealed a high frequency of H. pylori infection among CVD patients, as well as the potential link between H. pylori infection and an elevated risk of cardiovascular problems. H. pylori infection is most commonly associated with CAD and least associated with idiopathic dysrhythmias. Additionally, serological tests are the most commonly employed to identify H. pylori, with the usage of more beneficial procedures such as the urease breath test and stool Ag test being limited. Moreover, further study is needed to investigate the effect of H. pylori infection in less well-studied kinds of CVD, such as cerebrovascular disorders. Eventually, more research is needed to determine the true prevalence rate of H. pylori in CVD, especially in areas where statistics are unavailable.

Data availability

No datasets were generated or analysed during the current study.

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Authors and Affiliations

  1. Department of Microbiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran

    Somayeh Yaslianifard, Kimia Kazemi, Yousef Atefpour & Masoud Dadashi

  2. Department of Microbiology, Faculty of Medicine, Shahed University, Tehran, Iran

    Fatemeh Sameni

  3. Molecular Microbiology Research Center, Faculty of Medicine, Shahed University, Tehran, Iran

    Fatemeh Sameni

  4. Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Bahareh Hajikhani

  5. Department of Neurosurgery, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran

    Ali Baradaran Bagheri

  6. Department of Cardiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran

    Shahrooz Yazdani

  7. Cardiovascular Research Center, Shahid Rajaei Hospital, Alborz University of Medical Sciences, Karaj, Iran

    Shahrooz Yazdani

  8. Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran

    Masoud Dadashi

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  1. Somayeh Yaslianifard
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Contributions

MD and SY designed the study. BH performed the search strategy. FS, KK and YA conducted the data extraction. FS, KK, and YA wrote the manuscript. MD and FS carried out the statistical analysis. SHY and ABB separately evaluated inclusion and exclusion criteria. MD, BH, SHY, and FS did critical editing and revising of the text. MD, SY, and FS were responsible for the accuracy and integrity of the manuscript. All authors contributed to the article and approved the submitted version.

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Yaslianifard, S., Sameni, F., Kazemi, K. et al. Beyond the gut: a comprehensive meta-analysis on Helicobacter pylori infection and cardiovascular complications. Ann Clin Microbiol Antimicrob 24, 18 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12941-025-00788-6

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Annals of Clinical Microbiology and Antimicrobials

ISSN: 1476-0711

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