The n e w e ng l a n d j o u r na l of m e dic i n e

Original Article

Microplastics and Nanoplastics

in Atheromas and Cardiovascular Events
R. Marfella, F. Prattichizzo, C. Sardu, G. Fulgenzi, L. Graciotti, T. Spadoni,
N. D’Onofrio, L. Scisciola, R. La Grotta, C. Frigé, V. Pellegrini, M. Municinò,
M. Siniscalchi, F. Spinetti, G. Vigliotti, C. Vecchione, A. Carrizzo, G. Accarino,
A. Squillante, G. Spaziano, D. Mirra, R. Esposito, S. Altieri, G. Falco, A. Fenti,
S. Galoppo, S. Canzano, F.C. Sasso, G. Matacchione, F. Olivieri, F. Ferraraccio,
I. Panarese, P. Paolisso, E. Barbato, C. Lubritto, M.L. Balestrieri, C. Mauro,
A.E. Caballero, S. Rajagopalan, A. Ceriello, B. D’Agostino, P. Iovino,
and G. Paolisso​​

A BS T R AC T

BACKGROUND
The authors’ full names, academic degrees, Microplastics and nanoplastics (MNPs) are emerging as a potential risk factor for
and affiliations are listed in the Appendix. cardiovascular disease in preclinical studies. Direct evidence that this risk extends
Dr. Marfella can be contacted at ­raffaele​
.­marfella@​­unicampania​.­it or at the De- to humans is lacking.
partment of Advanced Medical and Sur-
gical Sciences, University of Campania METHODS
“Luigi Vanvitelli,” Piazza Miraglia, 2, We conducted a prospective, multicenter, observational study involving patients who
80138, Naples, Italy.
were undergoing carotid endarterectomy for asymptomatic carotid artery disease.
Drs. Marfella, Prattichizzo, Iovino, and The excised carotid plaque specimens were analyzed for the presence of MNPs with
G. Paolisso contributed equally to this
article.
the use of pyrolysis–gas chromatography–mass spectrometry, stable isotope analy-
sis, and electron microscopy. Inflammatory biomarkers were assessed with enzyme-
N Engl J Med 2024;390:900-10.
DOI: 10.1056/NEJMoa2309822
linked immunosorbent assay and immunohistochemical assay. The primary end
Copyright © 2024 Massachusetts Medical Society. point was a composite of myocardial infarction, stroke, or death from any cause
among patients who had evidence of MNPs in plaque as compared with patients
with plaque that showed no evidence of MNPs.
RESULTS
A total of 304 patients were enrolled in the study, and 257 completed a mean (±SD)
follow-up of 33.7±6.9 months. Polyethylene was detected in carotid artery plaque
of 150 patients (58.4%), with a mean level of 21.7±24.5 μg per milligram of plaque;
31 patients (12.1%) also had measurable amounts of polyvinyl chloride, with a mean
level of 5.2±2.4 μg per milligram of plaque. Electron microscopy revealed visible,
jagged-edged foreign particles among plaque macrophages and scattered in the
external debris. Radiographic examination showed that some of these particles in-
cluded chlorine. Patients in whom MNPs were detected within the atheroma were at
higher risk for a primary end-point event than those in whom these substances were
not detected (hazard ratio, 4.53; 95% confidence interval, 2.00 to 10.27; P<0.001).
CONCLUSIONS
In this study, patients with carotid artery plaque in which MNPs were detected had
a higher risk of a composite of myocardial infarction, stroke, or death from any cause
at 34 months of follow-up than those in whom MNPs were not detected. (Funded
by Programmi di Ricerca Scientifica di Rilevante Interesse Nazionale and others;
ClinicalTrials.gov number, NCT05900947.)

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 Microplastics and Nanoplastics in Atheromas

T
he production of plastics is con- MNPs were not detected) after enrollment. Pa-
stantly increasing, and this trajectory is set tients were recruited from Hospital Cardarelli,
to persist until 2050.1 Plastics can pollute Ospedale del Mare, and the University of Salerno
the environment by way of ocean currents, atmo- from August 1, 2019, to July 31, 2020. Consecutive
spheric winds, and terrestrial phenomena, contrib- patients with asymptomatic carotid artery steno-
uting to their widespread distribution.2,3 Once sis (as classified by the North American Symp-
released into nature, plastics are susceptible to tomatic Carotid Endarterectomy Trial14) for whom
degradation, leading to the formation of micro- intervention was indicated were screened for this
plastics (defined as particles smaller than 5 mm) study. A total of 447 consecutive patients were
and nanoplastics (particles smaller than 1000 approached to participate, and 312 agreed to
nanometers). Both types of particles trigger a undergo screening. Patients with asymptomatic
range of toxicologic effects.4,5 disease were selected for participation, in order
Several studies have shown that microplastics to maximize the chances of surviving the post-
and nanoplastics (MNPs) enter the human body procedure period and to minimize interpatient
through ingestion, inhalation, and skin exposure, variation in plaque phenotypes.15,16 Baseline clin-
where they interact with tissues and organs.5,6 ical examinations were conducted and electronic
MNPs have been found in selected human tissues, health records were evaluated to collect demo-
such as the placenta,7 lungs,8 and liver,9 as well as graphic, clinical, and therapeutic-intervention data.
in breast milk,10 urine,11 and blood.12 Recent stud- Blood samples were obtained according to stan-
ies performed in preclinical models have led to dard procedures after overnight fasting for analy-
the suggestion of MNPs as a new risk factor for sis of biochemical variables. After undergoing
cardiovascular diseases. Data from in vitro stud- carotid endarterectomy, the patients were followed
ies suggest that specific MNPs promote oxidative to monitor the incidence of nonfatal myocardial
stress, inflammation, and apoptosis in endothelial infarction, nonfatal stroke, and death from any
and other vascular cells; animal models support cause until July 1, 2023. Follow-up visits were
a role for MNPs in altered heart rate, cardiac- according to common clinical practice and were
function impairment, myocardial fibrosis, and not scheduled. Participants without visits during
endothelial dysfunction.13 However, the clinical the follow-up period were considered to be lost
relevance of these findings is unknown. Evidence to follow-up. Events were adjudicated by means
is lacking to show that MNPs infiltrate vascular of review of electronic health records by investi-
lesions in humans or to support an association gators who were unaware of the results of py-
between the burden of MNPs and cardiovascular rolysis–gas chromatography–mass spectrometry
disease. (and thus to group assignments). The protocol
To explore whether MNPs are detectable with- was approved by the local ethics review commit-
in atherosclerotic plaque and whether the burden tee (Università Vanvitelli Caserta). The participants
of MNPs is associated with cardiovascular dis- provided written informed consent, and we ad-
ease, we assessed the presence of these substanc- hered to the STROBE (Strengthening the Report-
es in surgically excised carotid artery plaque by ing of Observational Studies in Epidemiology)
means of pyrolysis–gas chromatography–mass guidelines checklist for reporting of data.17
spectrometry, stable isotope analysis, and elec- Specimens of the atheromatous plaque that
tronic microscopy. We then determined whether were surgically excised from the carotid artery
the presence of MNPs was associated with a com- bifurcation region at atherectomy were collected
posite end point of myocardial infarction, stroke, in glass tubes and then frozen in liquid nitrogen,
or death from any cause. fixed in 10% buffered formalin, or fixed in 2.5%
electronic microscopy–grade glutaraldehyde for
subsequent analyses. The abundance of 11 dif-
Me thods
ferent MNPs was measured with pyrolysis–gas
Study Design chromatography–mass spectrometry (a quantita-
We performed a prospective, multicenter, obser- tive technique that measures MNPs in combination
vational study in which patients were assigned to and does not distinguish between microplastics
groups (one group with plaque in which MNPs and nanoplastics), and results were corroborated
were detected and one group with plaque in which with the use of electron microscopy and stable

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 The n e w e ng l a n d j o u r na l of m e dic i n e

isotope analysis (see the Supplementary Methods of at least one of the two substances) or patients
section and Fig. S1 in the Supplementary Ap- with no evidence of MNPs. The distribution of
pendix, available with the full text of this article variables was assessed with the use of the Shapiro–
at NEJM.org). Samples were analyzed as they be- Wilk test. Continuous variables were compared
came available to researchers, who were unaware between the two groups with a t-test for normally
of outcome data. All the authors agreed to submit distributed data, the Mann–Whitney U test for
the manuscript for publication. non-normally distributed data, and Fisher’s exact
test for categorical variables. Linear regression
Patients analyses were performed to estimate the associa-
Patients were eligible if they were 18 to 75 years tion of the burden of MNPs with plaque markers.
of age, had asymptomatic extracranial high-grade Cox regression analysis was used to examine the
(>70%) internal carotid artery stenosis, and were association between the presence of MNPs with-
scheduled to undergo carotid endarterectomy. in plaque and the incidence of the composite
Exclusion criteria were evidence of heart failure, primary end point and was adjusted for age, sex,
valvular defects, malignant neoplasms, or second- body-mass index, total cholesterol, high-density
ary causes of hypertension. Patients with com- lipoprotein and low-density lipoprotein choles-
plications in the postoperative period before dis- terol, triglycerides, creatinine, diabetes, hyperten-
charge, who had incomplete data, or who were lost sion, and previous cardiovascular events. A two-
during follow-up were excluded from the analysis. sided P value of less than 0.05 was considered to
indicate statistical significance. All calculations
End Points were performed with the use of SPSS software,
The primary end point was a composite of non- version 12. Figures were prepared with the use
fatal myocardial infarction, nonfatal stroke, or of GraphPad Prism, version 9.1.2.
death from any cause among patients with plaque
containing MNPs and patients with plaque that R e sult s
did not contain those substances. Secondary end
points included levels of tissue biomarkers inter- Study Population and Plastics Burden
leukin-18, interleukin-1β, tumor necrosis factor α A total of 312 patients who were undergoing
(TNF-α), interleukin-6, CD68, CD3, and collagen carotid endarterectomy were screened. Of the
in patients with evidence of MNPs as compared patients screened, 8 had a stroke or died before
with those without. hospital discharge, and 47 had incomplete data
or were lost during follow-up (Fig. 1A). Of the
Statistical Analysis 257 patients who completed a mean (±SD) fol-
There were no previous data with which to gauge low-up of 33.7±6.9 months, 150 patients (58.4%)
a sample size. Therefore, an interim analysis that had a detectable amount of polyethylene in ex-
included the first 100 patients was performed to cised carotid plaque, and 31 of those (12.1%) also
calculate the sample size. We observed that 61 had a measurable amount of polyvinyl chloride in
patients had evidence of MNPs in plaque and the carotid plaque. Among patients with evidence
that such patients had a higher risk of a primary of these MNPs in plaque, the mean level of poly-
end-point event by a factor of 2.1, than patients ethylene was 21.7±24.5 μg per milligram of
without MNPs. Considering an alpha of 0.05, a plaque, and the mean level of polyvinyl chloride
beta of 0.2, a baseline event rate of 9 events per was 5.2±2.4 μg per milligram of plaque (Fig. 1B).
100 person-years in the group without evidence The patients’ characteristics at baseline are
of MNPs, and a planned follow-up of 3 years, we summarized in Table 1. Patients with evidence
calculated a sample size of 246 patients, with the of MNPs were younger; more likely to be men;
intention of using a proportional-hazards model less likely to have hypertension; more likely to
in the data analysis. We expected a 20% loss to have diabetes, cardiovascular disease, and dys-
follow-up and adjusted the sample size to 300 lipidemia; more likely to smoke; and had higher
patients. creatinine values than those without evidence of
After analysis of atherosclerotic plaque, pa- plastics in excised plaque; the other clinical vari-
tients were assigned to one of two groups: patients ables appeared similar in the two groups. There
with evidence of MNPs (having detectable levels were no apparent differences in the incidence of

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 Microplastics and Nanoplastics in Atheromas

MNPs according to the geographic areas where

A
the patients lived or the centers where they were
enrolled (Fig. S2). No substantive differences were 312 Patients were screened
found between the patients who were included in
the analysis and those who were excluded with 8 Were excluded
regard to the clinical characteristics of the pa- 6 Had a stroke
tients or the prevalence and the levels of detected 2 Died

MNPs (Table S1).

304 Were enrolled in the study
Electronic Microscopy and Analysis with
Stable Isotopes
47 Were excluded
To substantiate the results obtained with pyroly- 26 Had incomplete data
sis–gas chromatography–mass spectrometry and 21 Were lost to follow-up

to gain preliminary information about the size

of the MNP particles, we evaluated plaque sam- 257 Completed follow-up
ples that were positive for both polyethylene and
polyvinyl chloride from 10 randomly selected
patients using transmission electron microscopy
and scanning electron microscopy. Visualization 150 Had evidence of MNPs in 107 Did not have evidence of MNPs
carotid artery plaque in carotid artery plaque
with transmission electron microscopy showed
the presence of particles with jagged edges that
were probably of foreign origin within the foamy B
macrophages present in atheromatous plaque 150

and in the amorphous material of plaque (Fig. 2A

and Fig. S3A). These particles were almost all 100
smaller than 1 μm and were probably nanometers
µg/mg of Plaque

in size. 50
Observing the same slices using the back-scat- 25
tered electrons with scanning electron microscopy, 20
we made spectral x-ray maps from some particles 15
that resembled those seen on transmission elec- 10
tron microscopy with regard to size and shape 5
(Fig. 2B). These maps provided evidence of a re- 0
duction in the presence of carbon and oxygen in Polyvinyl Chloride Polyethylene
the plaque samples and a greater presence of chlo-
Figure 1. MNPs in Carotid Artery Plaque.
rine (Fig. S3B). To compare the elements detectable
Enrolled patients were screened for the presence of microplastics and
in the particles with those present in the back-
nanoplastics (MNPs) in carotid artery plaque excised during endarterecto-
ground, we obtained x-ray spectra from two iden- my (Panel A). Median and individual levels of polyethylene and polyvinyl
tical areas and confirmed that the chlorine con- chloride in excised carotid artery plaque that contained evidence of these
centration was higher inside the particles (Fig. compounds are shown in micrograms per milligram of atherosclerotic
S3B). As a further control, we also compared plaque (Panel B).
chlorine content in two adjacent identical areas
that were devoid of particles and found the levels
of chlorine to be similar (Fig. S3C). Given the leum-derived plastics have lower δ13C values (the
probable nonbiologic nature of chlorine at the ratio of carbon-13 to carbon-12) than human tis-
solid state, these results may confirm deposits of sues.18 This analysis identified two distinct clus-
polyvinyl chloride. Another example of such par- ters of patients — one group with higher isotopic
ticles is shown in Figure S3D; samples from 4 of values of δ13C and one with lower values — which
the 10 patients tested had chlorine levels detectable indicated higher and lower ratios, respectively, of
with this pattern. carbon-13 to carbon-12. Lower isotopic values of
Stable isotope analysis was performed on 26 δ13C could be due to contamination with MNPs,
random patient plaque samples because petro- since petroleum-derived material has an isotopic

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 The n e w e ng l a n d j o u r na l of m e dic i n e

Table 1. Characteristics of the Patients at Baseline.*

MNPs Present MNPs Not Present

Variable (N = 150) (N = 107)
Age (IQR) — yr 71 (65–75) 73 (67–77)
Male sex — no. (%) 116 (77.3) 79 (73.8)
Body-mass index (IQR)† 28 (27–29) 28 (26–29)
Hypertension — no. (%) 78 (52.0) 69 (64.5)
Systolic blood pressure (IQR) — mm Hg 124 (118–130) 127 (118–129)
Diastolic blood pressure (IQR) — mm Hg 78 (75–83) 77 (75–85)
Heart rate (IQR) — beats/min 85 (79–91) 81 (76–86)
Stenosis severity (IQR) — % 77 (73–83) 78 (73–83)
Diabetes — no. (%) 36 (24.0) 32 (29.9)
Cardiovascular disease — no. (%)‡ 50 (33.3) 35 (32.7)
Dyslipidemia — no. (%) 55 (36.7) 40 (37.4)
Total cholesterol (IQR) — mg/dl 150 (145–158) 147 (139–158)
LDL cholesterol (IQR) — mg/dl 77 (69–84) 74 (69–82)
HDL cholesterol (IQR) — mg/dl 42 (40–43) 42 (40–44)
Triglycerides (IQR) — mg/dl 178 (165–192) 182 (163–193)
Creatinine (IQR) — mg/dl 1.00 (0.90–1.10) 0.96 (0.96–1.06)
Smoker — no. (%) 24 (16.0) 17 (15.9)
Medication use — no. (%)
Beta-blockers 48 (32.0) 35 (32.7)
ACE inhibitors 75 (50) 53 (49.5)
ARBs 35 (23.3) 31 (29.0)
Calcium-channel blockers 13 (8.7) 8 (7.5)
Diuretics 17 (11.3) 16 (15.0)
Heparin 12 (8.0) 10 (9.3)
Antiplatelet drugs 146 (97.3) 105 (98.1)
Statin 143 (95.3) 101 (94.4)
Ezetimibe 26 (17.3) 20 (18.7)

* ACE denotes angiotensin-converting enzyme, ARBs angiotensin II–receptor blockers, HDL high-density lipoprotein, IQR
interquartile range, LDL low-density lipoprotein, and MNPs microplastics and nanoplastics.
† Body-mass index is the weight in kilograms divided by the square of the height in meters.
‡ Cardiovascular disease is defined as a history of acute coronary syndrome.

signal lower than that of human tissues. Lower samples (Fig. 3E) and levels of CD3 (Fig. 3F) and
isotopic values of δ13C were more evident in plaque CD68 (Fig. 3G), two markers of lymphocyte and
that had evidence of MNPs (Fig. S4). macrophage infiltration, respectively, were as-
sessed by means of immunohistochemical assay.
Plaque Phenotype Linear regression analysis revealed a correlation
Because previous data suggested that MNPs can between the amount of polyethylene present and
induce proinflammatory pathways,13 four inflam- the expression levels of these markers (Fig. S5).
matory markers — interleukin-18, interleukin-1β, Results of these analyses, stratified according to
interleukin-6, and TNF-α — were measured with the presence of polyethylene alone or in combi-
the use of enzyme-linked immunosorbent assay nation with polyvinyl chloride, are shown in
(Fig. 3A through 3D). Collagen content of plaque Figure S6.

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 Microplastics and Nanoplastics in Atheromas

Cardiovascular Events higher risk of having a primary end-point event

A primary end-point event (nonfatal myocardial than patients with no evidence of MNPs (hazard
infarction, nonfatal stroke, or death from any ratio, 4.53; 95% confidence interval [CI], 2.00 to
cause), occurred in 8 of 107 patients (7.5%) in 10.27; P<0.001) (Fig. 4), as shown by Cox re-
the group that did not have evidence of MNPs gression analysis with adjustment for risk fac-
(2.2 events per 100 patient-years) and in 30 of tors for cardiovascular disease (Table S3). The
150 patients (20.0%) in the group that had evi- unadjusted hazard ratio was 2.84 (95% CI, 1.50
dence of MNPs (6.1 events per 100 patient-years) to 5.40; P = 0.007). When the levels of MNPs were
at 33.7±6.9 months. The incidence of individual analyzed as a continuous variable, the results
components of the composite end point is shown showed an association with the primary end
in Table S2. Patients with MNPs in plaque had a point (Table S4).

A Transmission Electron Microscopy

Inside Macrophage Outside Macrophage

1 µm 1 µm

B Scanning Electron Microscopy Using Back-Scattered Electrons

10 µm 1 µm

Figure 2. Electron Microscopy Analysis of Atheromatous Plaque.

Panel A shows transmission electron microscopy images of particles of high internal electron transparency con-
toured by a very thin electron opaque line. These particles do not resemble usual organic material owing to their
particularly irregular shape. These particles (arrows) were detected inside living macrophages and outside in the
amorphous material of the plaque (arrows). Panel B shows images of the same specimen obtained with scanning
electron microscopy using back-scattered electrons, which showed macrophages dispersed in the amorphous
plaque material (arrows) and small particles of low-reflecting material contoured by a thin line of high-reflecting
material identified in the plaque (red boxes).

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 The n e w e ng l a n d j o u r na l of m e dic i n e

A B
500 500

(pg/mg of tissue)

(pg/mg of tissue)
400 400

Interleukin-1β
Interleukin-18
300 300

200 200

100 100

0 0
Patients with Patients without Patients with Patients without
MNPs MNPs MNPs MNPs

C D
500 400
(pg/mg of tissue)

(pg/mg of tissue)
400
300

Interleukin-6
300
TNF-α

200
200
100
100

0 0
Patients with Patients without Patients with Patients without
MNPs MNPs MNPs MNPs

E
50
Patients with MNPs Patients without MNPs
Collagen Content (%)

40

30

20

10

0
Patients with Patients without
MNPs MNPs

F
60
Patients with MNPs Patients without MNPs

40
CD3 (%)

20

0
Patients with Patients without
MNPs MNPs

G
60
Patients with MNPs Patients without MNPs

40
CD68 (%)

20

0
Patients with Patients without
MNPs MNPs

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 Microplastics and Nanoplastics in Atheromas

Figure 3 (facing page). Inflammatory Markers in Plaque 25

100 Patients with
Samples. Hazard ratio, 4.53
90 MNPs
20 (95% CI, 2.00–10.27)

Primary End-Point Events (%)

Panels A through D show the abundance of interleu- P<0.001
80
kin-18, interleukin-1β, tumor necrosis factor α 15
(TNF-α), and interleukin-6, respectively, assessed by 70
60 10
means of enzyme-linked immunosorbent assay. Panels
E, F, and G show the abundance of collagen, CD3, and 50 5 Patients without
CD68, respectively, measured by immunohistochemi- 40 MNPs
0
cal assay in the group of patients with evidence of 30 0 10 20 30 40
MNPs within the plaque and the group with no evi- 20
dence of MNPs. Medians and individual values are
10
shown.
0
0 10 20 30 40
Months since Enrollment
Discussion
No. at Risk
Among patients with asymptomatic high-grade Patients with MNPs 150 144 136 126 120
Patients without MNPs 107 105 103 99 99
(>70%) carotid artery stenosis who were under-
going carotid endarterectomy, those with evi- Figure 4. Associations between the Presence of MNPs and Cardiovascular
dence of MNPs within the carotid plaque had a Events.
greater incidence of a composite of myocardial Shown is the cumulative incidence curve of the composite outcome —
infarction, stroke, or death from any cause than nonfatal stroke, nonfatal myocardial infarction, or death from any cause.
patients who did not have evidence of MNPs The results were estimated with the use of Cox regression analysis with
adjustment for age, sex, body-mass index, total cholesterol, high-density
within the atheroma. Observational data from oc- lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides,
cupational-exposure studies suggest an increased creatinine, diabetes, hypertension, and previous cardiovascular events in
risk of cardiovascular disease among persons the group of patients with evidence of MNPs in plaque and the group of
who are exposed to plastics-related pollution, in- patients with no evidence of MNPs in plaque. The inset shows the same
cluding polyvinyl chloride, than that seen in the data on an expanded y axis.
general population.19-21 Mechanistic data from pre-
clinical models has proposed both direct translo-
cation of MNPs into the circulation and indirect humans have shown that MNPs of up to 30 μm
mechanisms as possible underpinnings of the in size have been detected in liver samples, up to
cardiovascular toxic effects observed with MNPs, 10 μm in placenta samples, up to 88 μm in lung
as has been noted with other nanoparticles such samples, up to 12 to 15 μm in breast milk and
as inhaled gold nanoparticles of similar size to urine, and more than 700 nm in whole blood.7-12
MNPs.22 A range of studies in mice and rats Qualitatively, pyrolysis–gas chromatography–
showed a wide distribution of MNPs after both mass spectrometry analysis indicated that, among
inhalation and ingestion, with consistent accu- the 11 MNPs tested, polyethylene and polyvinyl
mulations in highly vascularized organs and the chloride were detectable within the carotid plaque
heart.23,24 Particle size influences the ability of in microgram quantities (μg per milligram of
MNPs to reach multiple tissues. According to a plaque). Previous studies that used the same tech-
World Health Organization statement, MNPs nology showed that polyethylene was found in
larger than 150 μm or 10 μm in diameter, re- approximately 25% of the whole-blood samples
spectively, are not absorbed into blood and do derived from healthy volunteers, with a maximum
not penetrate blood vessels.25 Our findings sug- concentration of 7.1 μg per milliliter.12 Other
gest that nanoplastics, rather than microplastics, studies have suggested that polyethylene and
might accumulate in sites of atherosclerosis. polyvinyl chloride were also the most abundant
Indeed, the large majority of particles detected MNPs found in human breast milk and urine,10,11
in the current study were also below the 200-nm with polyethylene fibers observed in human lung
threshold suggested for gut and other barriers tissue at a concentration of 1 particle per gram
and were visible in the extracellular space as scat- of tissue.8 The presence of polyvinyl chloride has
tered debris, which aligns with the notion that also been shown in a consistent number of liver
the absorption and distribution of MNPs increase samples obtained from patients with cirrhotic dis-
as particle size decreases.26 Data from studies in ease, in the range of a few particles per gram of

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 The n e w e ng l a n d j o u r na l of m e dic i n e

tissue.9 Polyethylene nanoplastics have been re- the life course of the patient or, more broadly,
ported to induce a range of noxious effects on the health status and behaviors of the patients.
the cardiovascular system in zebrafish embryos, In addition, we did not consider levels of exposure
promoting the development of pericardial effu- to PM2.5 and PM10, which is an emerging risk fac-
sions, the inhibition of angiogenesis, and the in- tor for cardiovascular disease.31
duction of a prothrombotic status.27 Similar data Our study has limitations. Despite the preven-
are available from studies of the effects of poly- tive measures adopted, laboratory contamination
vinyl chloride.28 However, in most preclinical stud- cannot be firmly ruled out. Even though we ap-
ies, high levels of MNPs are assessed — orders plied updated procedures to collect and analyze
of magnitude beyond those observed in the pres- plaque specimens, the residual risk of contami-
ent study, a factor that makes extrapolation of the nation might exist. Future studies performed with
relevance of preclinical findings to humans dif- the use of clean rooms, where there is no plastic
ficult. in any form except the material under study,
Polyethylene and polyvinyl chloride, in their might corroborate our observations. We did not
various forms, are used in a wide range of ap- have socioeconomic data available for our study
plications, including the production of food and population. Income and education, among other
cosmetics containers and water pipes. MNPs have conditions, are linked to a wide range of out-
been found in drinking water, a large range of comes and might be particularly relevant.32 Our
foods, cosmetic products, and air, also in a form findings pertain only to a population of asymp-
bound to fine, inhalable particulate matter with tomatic patients undergoing carotid endarterec-
an aerodynamic diameter of 2.5 μm or less (PM2.5) tomy, who may not be representative of the gen-
and transported long distances by wind.5,6,29,30 eral population.14 Thus, our findings may not be
Given the wide distribution and availability of generalizable. The representativeness of patients
MNPs, the attribution of all potential sources in who participated in the study is shown in Table
humans is nearly impossible. Our study was not S5. We did not explore the variables of food and
designed specifically to explore the possible sourc- drinking water, which may be linked to accumu-
es of plastics underlying the presence of MNPs lation of MNPs in humans.25,33,34 Thus, it is pos-
within carotid plaque. Comparison of data on sible that the putative role of MNPs in driving
the basis of the locations of patients’ homes and cardiovascular disease might be limited if com-
of the recruitment centers did not reveal obvious pared with canonical risk factors, given that over
differences. Similarly, we cannot establish why a period of decades in which exposure to plastics
only polyethylene and polyvinyl chloride, among has presumably been increasing, the rate of car-
the 11 types of plastics assessed, were detected. diovascular disease has been falling.35 However,
Studies in animal models suggest that the physi- results of our study show that patients with
cochemical features of different MNPs influence MNPs that were detected in carotid artery plaque
whether they reach distant organs.30,31 Additional have a higher risk of a composite end point of
work is needed to assess whether polyethylene myocardial infarction, stroke, or death from any
and polyvinyl chloride accumulate preferentially cause at 34 months of follow-up.
within plaque and whether they are more patho-
Supported by a grant (2020LM8WNW) from Programmi di
genic than other types of MNPs in this regard. Ricerca Scientifica di Rilevante Interesse Nazionale (scientific
It is important to note that our results do not research programs of high national interest) to Dr. Marfella,
prove causality. The association between the support from the Italian Ministry of Health–Ricerca Cor-
rente to IRCCS MultiMedica, and grants (1R35ES031702 and
presence of MNPs within plaque and the inci- R01ES017290) from the National Institutes of Health to Dr.
dence of a composite of cardiovascular disease Rajagopalan.
or death outcomes may also entail the risk from Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
exposure to other residual, unmeasured confound- A data sharing statement provided by the authors is available
ing variables, such as unknown exposures during with the full text of this article at NEJM.org.

Appendix
The authors’ full names and academic degrees are as follows: Raffaele Marfella, M.D., Ph.D., Francesco Prattichizzo, Ph.D., Celestino
Sardu, M.D., Ph.D., Gianluca Fulgenzi, Ph.D., Laura Graciotti, Ph.D., Tatiana Spadoni, Ph.D., Nunzia D’Onofrio, Ph.D., Lucia Sciscio-
la, Ph.D., Rosalba La Grotta, Ph.D., Chiara Frigé, M.Sc., Valeria Pellegrini, M.Sc., Maurizio Municinò, M.D., Mario Siniscalchi, M.D.,

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 Microplastics and Nanoplastics in Atheromas

Ph.D., Fabio Spinetti, M.D., Gennaro Vigliotti, M.D., Carmine Vecchione, M.D., Albino Carrizzo, Ph.D., Giulio Accarino, Ph.D., Anto-
nio Squillante, M.D., Giuseppe Spaziano, Ph.D., Davida Mirra, Ph.D., Renata Esposito, Ph.D., Simona Altieri, Ph.D., Giovanni Falco,
Ph.D., Angelo Fenti, Ph.D., Simona Galoppo, M.Sc, Silvana Canzano, Ph.D., Ferdinando C. Sasso, M.D., Ph.D., Giulia Matacchione, Ph.D.,
Fabiola Olivieri, Ph.D., Franca Ferraraccio, M.D., Iacopo Panarese, M.D., Pasquale Paolisso, M.D., Emanuele Barbato, M.D., Ph.D.,
Carmine Lubritto, Ph.D., Maria L. Balestrieri, Ph.D., Ciro Mauro, M.D., Augusto E. Caballero, M.D., Sanjay Rajagopalan, M.D., Antonio
Ceriello, M.D., Bruno D’Agostino, M.D., Ph.D., Pasquale Iovino, Ph.D., and Giuseppe Paolisso, M.D.
The authors’ affiliations are as follows: the Departments of Advanced Medical and Surgical Sciences (R.M., C.S., L.S., F.C.S., G.P.),
Precision Medicine (N.D., M.L.B.), Engineering (A.F., S.G.), and Mental Health and Public Medicine, Section of Statistics (F.F., I.P.),
University of Campania Luigi Vanvitelli, the Department of Forensic, Evaluative, and Necroscopic Medicine, Azienda Sanitaria Locale
Napoli 2 Nord (M.M.), the Department of Cardiology, Hospital Cardarelli (M.S., C.M.), the Department of Vascular Surgery, Ospedale
del Mare Azienda Sanitaria Locale Napoli 1 (F.S., G.V.), Environmental Technologies, spinoff of University of Campania Luigi Vanvi-
telli (S.C.), and the Department of Advanced Biomedical Sciences, University Federico II (P.P.), Naples, IRCCS MultiMedica, Milan (F.P.,
R.L.G., C.F., V.P., A. Ceriello), the Departments of Clinical and Molecular Sciences (G. Fulgenzi, F.O.) and Excellence SBSP–Biomedical
Sciences and Public Health (L.G., T.S.), Polytechnic University of Marche, and IRCCS Istituto Nazionale Ricovero e Cura per An-
ziani (G.M., F.O.), Ancona, the Vascular Physiopathology Unit, IRCCS Neuromed, Pozzilli (C.V.), the Department of Medicine, Surgery,
and Dentistry, University of Salerno, Salerno (C.V., A. Carrizzo, G.A., A.S.), the Department of Environmental, Biologic, and Pharma-
ceutical Sciences and Technologies, University of Campania Luigi Vanvitelli, Caserta (G.S., D.M., R.E., S.A., G. Falco, C.L., B.D., P.I.),
and the Department of Clinical and Molecular Medicine, Sapienza University of Rome (E.B.), and UniCAMILLUS, International Medical
University (G.P.), Rome — all in Italy; Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium (P.P.); Harvard Medical School and
the Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston (A.E.C.); and University Hospitals,
Case Western Reserve School of Medicine, Cleveland (S.R.).

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