We ran a double-blind randomized, placebo-controlled study to inspect the endotoxemia, and inflammation levels in 44 CAD subjects. This trial was done at Shahid Madani hospital, as cardiology and heart surgery hospital of Tabriz University of Medical Sciences, Tabriz, Iran. Our study was in agreement with the Helsinki Declaration of the World Medical Association (2000) and was accepted by our local ethics committee of Tabriz University of Medical sciences (IR.TBZMED.REC.1397.184) and also was listed in the Iranian Registry of Clinical Trials (IRCT) (IRCT20121028011288N15). All patients admitted to this hospital with a diagnosis of CAD were considered for participation in the study and screened by a cardiologist for eligibility. Patients were selected a few days after the PCI and/or conditions were stable. The inclusion criteria were as follows: having CAD; maintaining them during the course of the trial; normal diet; and Body Mass Index (BMI) =25-35 kg/m2. Patients were excluded if they refused to participate or if they had a history of gastrointestinal disorders, if they had thyroid, renal, pancreatic, or liver diseases; if they were lactating or pregnant; if they are taking antibiotics, probiotics, prebiotics, and inflammatory drugs for one month before the intervention or during the intervention. A third party who was blind to the study gave the randomization sequence extracted from allocation software. The contributors, investigators and the medical providers were blinded after assignment to interventions. Informed consent was gotten from each participant. Calculation of sample size was based on a parallel two group randomized clinical trial with measurements of LPS at two time points. Considering a type I error of α= 0.05 and a medium to large effect size, a sample of 44 participants would suffice to demonstrate superiority of the probiotic compared to the placebo group with a power of 80% . All 44 contributors completed the study and none of them dropped their participation (Fig 1. CONSORT Flow diagram).
A blind trial at two levels (researcher, participants), placebo-controlled, randomized, clinical design was used to examine the effect of probiotic supplementation on endotoxemia in patients with CAD. Each qualified contributor was randomly allocated into probiotic or placebo group, according to 1:1 equal proportion rule. The order of random allocation was made by random sequence software. The random numbers were kept by a free person not complicated in the assessment of the patient, or in the data collection and analysis. In the current study, patients were randomly assigned into two groups to receive whichever probiotic supplements (n=22) or placebo (n=22) for 3 months. Both participants and researchers were unaware of the treatment allocation.
All the participants received a moderate calorie restricted dietary plan during 12 weeks’ intervention period. In this study, the program was designed to enable weight loss of 7–10% of weight, at a rate of 0.5–1 kg/wk throughout the intervention. The weight-loss program was calculated to introduce a 500- to 1000-kcal energy deficit based on estimated energy requirements at the baseline of the intervention. Patients in the probiotic group received one probiotic capsule daily containing a Lactobacillus rhamnosus 1.6 ×109 colony-forming unit (CFU) with their lunch. In the placebo (control) group, the capsules contained maltodextrin (Tak Gen Zist Pharmaceutical Company, Tehran, Iran). The physical properties of the placebo were identical in terms of shape, color, size, packaging, and smell but contained no bacteria. Phone contacts were made to ensure adherence twice a month. Compliance to supplementation was established by requesting participants to return the medication containers.
In addition, a moderate calorie restriction diet plan intended for all the participants during 12 weeks’ intervention period. The program was planned to facilitate weight loss of 7–10% of weight, at an amount of 0.5–1 kg/wk throughout the intervention. Calorie intake was planned based on individual features of the subjects and with the aim of daily energy restriction (500 kcal fewer than the total energy requirements [TEE] estimated by Mifflin–St Jeor equation). The diets were provided 55 ~ 60% of TEE from carbohydrate, 10 ~ 15% from protein, and 25 ~ 35% from fat.
Dietary intake was assessed using a dietary record at month 0, 1 and 3 of the intervention. We used Nutritionist IV software adjusted for Iranian diets to acquire nutrient intakes of participants based on the average of three-day food diaries.
Physical Activity Assessment
The physical activity assessment was gotten to monitor patient’s usual physical activity levels throughout the study. The validated short-form International Physical Activity Questionnaire (IPAQ) was used to measure the participant’s physical activity. Based on previous studies, physical activities were classified as low, moderate, and high.
Assessment of anthropometric indices
Body weight was assessed via a scale with 250 gr accuracy (Seca, Hamburg, Germany) and patients were measured while wearing a minimum dress and without shoes. Height without shoes was measured by a tape with 0.5-cm accuracy. BMI was computed by dividing weight (Kg) by height2 (m). To avoid measurement bias, all measurements were taken by a trained dietitian.
After an overnight fasting (12 hours), blood was collected and supplements was provided to the participants. Blood serum was obtained from whole blood through centrifugation at 2500 rpm for 10 min. FBS and lipid profile were examined on the day of sampling, and residual serum was stored at -20 C until the analyses were done. Endotoxin, and inflammatory markers were measured using enzyme-linked immunosorbent assay  kits as follows: Interleukin 1 beta (IL-1β) (intra-assay variation = 5.8%, normal range = 0.02-6 pg/mL, inter-assay variation = 9.06%, sensitivity = 0.01 pg/mL), Toll-Like Receptor 4 (TLR-4) (normal range = 0.05-15 ng/mL, intra-assay variation = 4.58%, inter-assay variation = 7.8%, sensitivity = 0.027 ng/mL), IL-10 (normal range = 0.2-100 ng/dl, intra-assay variation = 10%), and, LPS (inter-assay CV = 10.0% , detectable range = 12.00 – 1000 ng/ml).
The data were analyzed via SPSS software (version 21; SPSS Inc., Chicago, IL) and the outcomes were stated as mean ± SD. To determine the normal distribution of variables, we used skewness and kurtosis test. Paired samples t-test was applied for within-group comparisons (end-point vs. baseline). To adjust for several confounders, we did analysis of covariance (ANCOVA) in which the confounding effect of these variables were taken into account which was used to determine the statistically significant pairwise differences. The analyses were conducted using an intention-to-treat approach . Circulating endotoxin level was intended as a primary outcome, while inﬂammatory markers were defined as secondary outcomes. For all statistical tests, a P value less than 0.05 was interpreted as statistically significant.