Rationale and Design of Sodium Tanshinone IIA Sulfonate in Left Ventricular Remodeling Secondary to Acute Myocardial Infarction (STAMP-REMODELING) Trial: A Randomized Controlled Study

Effects of sodium tanshinone IIA sulfonate injection on inflammatory factors and vascular endothelial function in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A systematic review and meta-analysis of randomized clinical trials

Background: Patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) therapy may experience further damage to the vascular endothelium, leading to increased inflammatory response and in-stent thrombosis. In many clinical studies, sodium tanshinone IIA sulfonate injection (STS) has been found to reduce inflammatory factors and enhance vascular endothelial function in patients with ACS while improving the prognosis of PCI. However, to date, there has been no systematic review assessing the effectiveness and safety of STS on inflammatory factors and vascular endothelial function. Purpose: The aim of this study is to systematically review the effects of STS on inflammatory factors and endothelial function in patients with ACS treated with PCI. Methods: Until October 2022, eight literature databases and two clinical trial registries were searched for randomized controlled trials (RCTs) investigating STS treatment for ACS patients undergoing PCI. The quality of the included studies was assessed using the Cochrane Risk Assessment Tool 2.0. Meta-analysis was performed using RevMan 5.4 software. Results: Seventeen trials met the eligibility criteria, including 1,802 ACS patients undergoing PCI. The meta-analysis showed that STS significantly reduced high-sensitivity C-reactive protein (hs-CRP) levels (mean difference [MD = -2.35, 95% CI (-3.84, -0.86), p = 0.002], tumor necrosis factor-alpha (TNF-α) levels (standard mean difference [SMD = -3.29, 95%CI (-5.15, -1.42), p = 0,006], matrix metalloproteinase-9 (MMP-9) levels [MD = -16.24, 95%CI (-17.24, -15.24), p < 0.00001], and lipid peroxidation (LPO) levels [MD = -2.32, 95%CI (-2.70, -1.93), p < 0.00001], and increased superoxide dismutase (SOD) levels [SMD = 1.46, 95%CI (0.43, 2.49), p = 0,006] in patients with ACS. In addition, STS significantly decreased the incidence of major adverse cardiovascular events (relative risk = 0.54, 95%CI [0.44, 0.66], p < 0.00001). The quality of evidence for the outcomes was assessed to be very low to medium. Conclusion: STS can safely and effectively reduce the levels of hs-CRP, TNF-α, MMP-9, and LPO and increase the level of SOD in patients with ACS treated with PCI. It can also reduce the incidence of adverse cardiovascular events. However, these findings require careful consideration due to the small number of included studies, high risk of bias, and low to moderate evidence. In the future, more large-scale and high-quality RCTs will be needed as evidence in clinical practice.

Targeting Oxidative Stress and Endothelial Dysfunction Using Tanshinone IIA for the Treatment of Tissue Inflammation and Fibrosis

Salvia miltiorrhiza Burge (Danshen), a member of the Lamiaceae family, has been used in traditional Chinese medicine for many centuries as a valuable medicinal herb with antioxidative, anti-inflammatory, and antifibrotic potential. Several evidence-based reports have suggested that Salvia miltiorrhiza and its components prevent vascular diseases, including myocardial infarction, myocardial ischemia/reperfusion injury, arrhythmia, cardiac hypertrophy, and cardiac fibrosis. Tanshinone IIA (TanIIA), a lipophilic component of Salvia miltiorrhiza, has gained attention because of its possible preventive and curative activity against cardiovascular disorders. TanIIA, which possesses antioxidative, anti-inflammatory, and antifibrotic properties, could be a key component in the therapeutic potential of Salvia miltiorrhiza. Vascular diseases are often initiated by endothelial dysfunction, which is accompanied by vascular inflammation and fibrosis. In this review, we summarize how TanIIA suppresses tissue inflammation and fibrosis through signaling pathways such as PI3K/Akt/mTOR/eNOS, TGF-β1/Smad2/3, NF-κB, JNK/SAPK (stress-activated protein kinase)/MAPK, and ERK/Nrf2 pathways. In brief, this review illustrates the therapeutic value of TanIIA in the alleviation of oxidative stress, inflammation, and fibrosis, which are critical components of cardiovascular disorders.

Guanxin V Acts as an Antioxidant in Ventricular Remodeling

Background: Our previous studies have shown that Guanxin V (GXV) is safe and effective in the treatment of ventricular remodeling (VR), but its mechanism related to oxidative stress has not been studied deeply.

Methods: We applied integrating virtual screening and network pharmacology strategy to obtain the GXV-, VR-, and oxidative stress-related targets at first, and then highlighted the shared targets. We built the networks and conducted enrichment analysis. Finally, the main results were validated by molecular docking and solid experiments.

Results: We obtained 251, 11,425, and 9,727 GXV-, VR-, and oxidative stress-related targets, respectively. GXV-component-target-VR and protein–protein interaction networks showed the potential mechanism of GXV in the treatment of VR. The following enrichment analysis results gathered many biological processes and “two GXV pathways” of oxidative stress-related to VR. All our main results were validated by molecular docking and solid experiments.

Conclusion: GXV could be prescribed for VR through the mechanism, including complex interactions between related components and targets, as predicted by virtual screening and network pharmacology and validated by molecular docking and solid experiments. Our study promotes the explanation of the biological mechanism of GXV for VR.

Pharmacological basis of tanshinone and new insights into tanshinone as a multitarget natural product for multifaceted diseases

Drug development has long included the systematic exploration of various resources. Among these, natural products are one of the most important resources from which novel agents are developed due to the multiple pharmacologic effects of these natural products on diseases. Tanshinone, a representative natural product, is the main compound extracted from the dried root and rhizome of Salvia miltiorrhiza Bge. Research on tanshinone began in the early 1930s. With the in-depth investigation of an increasing number of identified analogs, tanshinone has demonstrated a wide variety of bioactivities and contradicted the saying, 'You can't teach an old dog new tricks'. This review is focused on the pharmacological action of tanshinone and status of research on tanshinone in recent years. The mechanism of tanshinone has also drawn much attention, with the findings of representative targets and pathways of tanshinone. The most recent studies have comprehensively shown that tanshinone can be used to treat leukemia and solid carcinoma, protect against cardiovascular and cerebrovascular diseases, and alleviate liver- and kidney-related diseases, among its other effects. Multiple signaling pathways, including antiproliferative, antiapoptotic, anti-inflammatory, and antioxidative stress pathways, are involved in its actions.

AFC1 Compound Attenuated MI/R-Induced Ventricular Remodeling via Inhibiting PDGFR and STAT Pathway

Background: Effective interventions to improve the outcome of patients subjected to myocardial ischemia reperfusion (MI/R) are urgent in clinical settings. Tanshinone IIA (TSA) is reported to attenuate myocardial injury and improve ventricular remodeling post MI/R. Here, we evaluated the efficacy of AFC1 compound that is similar to TSA structure in murine MI/R models. We found that AFC1 had a comparable effect of improving murine cardiac function after MI/R while it was superior to TSA in safety profile. Administration of AFC1 reduced reactive oxygen species (ROS) production, inflammatory cells infiltration, and the expression of platelet derived growth factor receptors (PDGFR) in infarcted myocardium. Treatment with AFC1 also attenuated MI/R-induced cardiac remodeling and contributed to the recovery of cardiac function. Additionally, AFC1 reversed the elevation of PDGFR expression induced by PDGF-AB in both neonatal rat cardiomyocytes (NCMs) and neonatal rat cardiac fibroblasts (NCFs) and suppressed PDGF-AB induced NCM hypertrophy via STAT3 pathway and NCF collagen synthesis through p38-MAPK signaling in vitro. Similarly, AFC1 may contribute to the recovery of cardiac function in mice post MI/R via suppressing STAT signaling. Our results confirmed that AFC1 exerts anti-hypertrophic and anti-fibrotic effects against MI/R-induced cardiac remodeling, and suggest that AFC1 may have a promising potential in improving the outcome of patients who suffered from MI/R.

Sodium tanshinone IIA sulfonate: A review of pharmacological activity and pharmacokinetics

Sodium tanshinone IIA sulfonate (STS) is a water-soluble derivate of tanshinone IIA (Tan IIA) which is an active lipophilic constitute of Chinese Materia Medica Salvia miltiorrhiza Bge. (Danshen). STS presents multiple pharmacological activities, including anti-oxidant, anti-inflammation and anti-apoptosis, and has been approved for treatment of cardiovascular diseases by China State Food and Drug Administration (CFDA). In this review, we comprehensively summarized the pharmacological activities and pharmacokinetics of STS, which could support the further application and development of STS. In the recent decades, numerous experimental and clinical studies have been conducted to investigate the potential treatment effects of STS in various diseases, such as heart diseases, brain diseases, pulmonary diseases, cancers, sepsis and so on. The underlying mechanisms were most related to anti-oxidative and anti-inflammatory effects of STS via regulating various transcription factors, such as NF-κB, Nrf2, Stat1/3, Smad2/3, Hif-1α and β-catenin. Iron channels, including Ca²⁺, K⁺ and Cl^- channels, were also the important targets of STS. Additionally, we emphasized the differences between STS and Tan IIA despite the interchangeable use of Tan IIA and STS in many previous studies. It is promising to improve the efficacy and reduce side effects of chemotherapeutic drug by the combination use of STS in canner treatment. The application of STS in pregnancy needs to be seriously considered. Moreover, the drug-drug interactions between STS and other drugs needs to be further studied as well as the complications of STS.

Exploration of Multiple Signaling Pathways Through Which Sodium Tanshinone IIA Sulfonate Attenuates Pathologic Remodeling Experimental Infarction

The level of maladaptive myocardial remodeling consistently contributes to the poor prognosis of patients following a myocardial infarction (MI). In this study, we investigated whether and how sodium tanshinone IIA sulfonate (STS) would attenuate the post-infarct cardiac remodeling in mice model of MI developing after surgical ligation of the left coronary artery. All mice subjected to experimental MI or to the sham procedure were then treated for the following 4 weeks, either with STS or with a vehicle alone. Results of our studies indicated that STS treatment of MI mice prevented the left ventricular dilatation and improved their cardiac function. Results of further tests, aimed at mechanistic explanation of the beneficial effects of STS, indicated that treatment with this compound enhanced the autophagy and, at the same time, inhibited apoptosis of the cardiomyocytes. Meaningfully, we have also established that myocardium of STS-treated mice displayed significantly higher levels of adenosine monophosphate kinase than their untreated counterparts and that this effect additionally associated with the significantly diminished activities of apoptotic promoters: mammalian target of rapamycin and P70S6 kinase. Moreover, we also found that additional administration of the adenosine monophosphate kinase inhibitor (compound C) or autophagy inhibitor (chloroquine) practically eliminated the observed beneficial effects of STS. In conclusion, we suggest that the described multistage mechanism triggered by STS treatment enhanced autophagy, thereby attenuating pathologic remodeling of the post-infarct hearts.

Salvia miltiorrhiza in Treating Cardiovascular Diseases: A Review on Its Pharmacological and Clinical Applications

Bioactive chemical constitutes from the root of Salvia miltiorrhiza classified in two major groups, viz., liposoluble tanshinones and water-soluble phenolics. Tanshinone IIA is a major lipid-soluble compound having promising health benefits. The in vivo and in vitro studies showed that the tanshinone IIA and salvianolate have a wide range of cardiovascular and other pharmacological effects, including antioxidative, anti-inflammatory, endothelial protective, myocardial protective, anticoagulation, vasodilation, and anti-atherosclerosis, as well as significantly help to reduce proliferation and migration of vascular smooth muscle cells. In addition, some of the clinical studies reported that the S. miltiorrhiza preparations in combination with Western medicine were more effective for treatment of various cardiovascular diseases including angina pectoris, myocardial infarction, hypertension, hyperlipidemia, and pulmonary heart diseases. In this review, we demonstrated the potential applications of S. miltiorrhiza, including pharmacological effects of salvianolate, tanshinone IIA, and its water-soluble derivative, like sodium tanshinone IIA sulfonate. Moreover, we also provided details about the clinical applications of S. miltiorrhiza preparations in controlling the cardiovascular diseases.

Rebuilding Postinfarcted Cardiac Functions by Injecting TIIA@PDA Nanoparticle-Cross-linked ROS-Sensitive Hydrogels

Drug-loaded injectable hydrogels have been proven to possess huge potential for applications in tissue engineering. However, increasing the drug loading capacity and regulating the release system to adapt to the microenvironment after myocardial infarction face a huge challenge. In this research, an ROS-sensitive injectable hydrogel strengthened by self-nanodrugs was constructed. A hyperbranched ROS-sensitive macromer (HB-PBAE) with multiacrylate end groups was synthesized through dynamic controlled Michael addition. Meanwhile, a simple protocol based on dopamine polymerization was employed to generate a polydopamine (PDA) layer deposited on the tanshinone IIA (TIIA) nanoparticles (NPs) formed from spontaneous hydrophobic self-assembly. The HB-PBAE reacted with thiolate-modified hyaluronic acid (HA-SH) to form an in situ hydrogel, where TIIA@PDA NPs can be conveniently entrapped through the chemical cross-link between thiolate and quinone groups on PDA, which doubles the modulus of hydrogels. The in vivo degradation behavior of the hydrogels was characterized by MRI, exhibiting a much slower degradation behavior that is markedly different from that of in vitro. Importantly, a significant improvement of cardiac functions was achieved after hydrogel injection in terms of increased ejection fraction and decreased infarction size, accompanied by inhibition of the expression of inflammation factors, such as IL-1β, IL-6, and TNF-α.

Tongguan Capsule Mitigates Post-myocardial Infarction Remodeling by Promoting Autophagy and Inhibiting Apoptosis: Role of Sirt1

Left ventricular (LV) adverse remodeling and the concomitant functional deterioration contributes to the poor prognosis of patients with myocardial infarction (MI). Thus, a more effective treatment strategy is needed. Tongguan capsule (TGC), a patented Chinese medicine, has been shown to be cardioprotective in both humans and animals following ischemic injury, although its precise mechanism remains unclear. To investigate whether TGC can improve cardiac remodeling in the post-infarct heart, adult C57/BL6 mice underwent coronary artery ligation and were administered TGC or vehicle (saline) for 6 weeks. The results demonstrated that the TGC group showed significant improvement in survival ratio and cardiac function and structure as compared to the vehicle group. Histological and western blot analyses revealed decreased cellular inflammation and apoptosis in cardiomyocytes of the TGC group. Furthermore, TGC upregulated the Atg5 expression and LC3II-to-LC3I ratio but downregulated autophagy adaptor p62 expression, suggesting that TGC led to increased autophagic flux. Interestingly, with the administration of 3-methyladenine, an autophagy inhibitor, in conjunction with TGC, the aforesaid effects significantly decreased. Further mechanistic studies revealed that TGC increased silent information regulator 1 (Sirt1) expression to reduce the phosphorylation of the mammalian target of rapamycin and its downstream effectors P70S6K and 4EBP1. Moreover, the induction of Sirt1 by TGC was inhibited by the specific inhibitor EX527. In the presence of EX527, TGC-induced autophagy-specific proteins were downregulated, while apoptotic and inflammatory factors were upregulated. In summary, our results demonstrate that TGC improved cardiac remodeling in a murine model of MI by preventing cardiomyocyte inflammation and apoptosis but enhancing autophagy through Sirt1 activation.

Salvia miltiorrhizaBurge (Danshen): a golden herbal medicine in cardiovascular therapeutics

Salvia miltiorrhiza Burge (Danshen) is an eminent medicinal herb that possesses broad cardiovascular and cerebrovascular protective actions and has been used in Asian countries for many centuries. Accumulating evidence suggests that Danshen and its components prevent vascular diseases, in particular, atherosclerosis and cardiac diseases, including myocardial infarction, myocardial ischemia/reperfusion injury, arrhythmia, cardiac hypertrophy and cardiac fibrosis. The published literature indicates that lipophilic constituents (tanshinone I, tanshinone IIa, tanshinone IIb, cryptotanshinone, dihydrotanshinone, etc) as well as hydrophilic constituents (danshensu, salvianolic acid A and B, protocatechuic aldehyde, etc) contribute to the cardiovascular protective actions of Danshen, suggesting a potential synergism among these constituents. Herein, we provide a systematic up-to-date review on the cardiovascular actions and therapeutic potential of major pharmacologically active constituents of Danshen. These bioactive compounds will serve as excellent drug candidates in small-molecule cardiovascular drug discovery. This article also provides a scientific rationale for understanding the traditional use of Danshen in cardiovascular therapeutics.

Tanshinone IIA prevents left ventricular remodelling via the TLR4/MyD88/NF-κB signalling pathway in rats with myocardial infarction

In this study, we aim to investigate the role of tanshinone IIA in myocardial infarction (MI), especially in left ventricular remodelling (VR) and the underlying mechanism involving the TLR4/MyD88/NF‐κB signalling pathway. Sprague‐Dawley (SD) rats (n = 96) were selected, and 12 of them underwent sham surgery. The remaining 84 rats were subjected to MI modelling. HE and MT staining were carried out to estimate infract size, histopathological changes and fibrosis degree. Macrophage infiltration and cardiomyocyte apoptosis were evaluated by immunohistochemistry and TUNEL staining. Reverse transcription quantitative polymerase chain reaction (RT‐qPCR) and Western blotting were used to determine the expression levels of TLR4, MyD88 and NF‐κB. Serum levels of IL‐2, IL‐6, IL‐8, TNF‐a, procollagen I Cpropeptide (PICP), and procollagen III N‐propeptide (PIIINP) were measured using enzyme‐linked immunosorbent assay (ELISA). The heart weight/body weight, mean arterial pressure (MAP), left ventricular end‐systolic pressure (LVESP), +dP/dt and −dP/dt increased while the ventricular function and the left ventricular end‐diastole pressure (LVEDP) decreased in MI rats. Compared with the rats undergoing sham surgery, MI rats showed larger infarct size, severer fibrosis, higher expression levels of TLR4, NF‐κB‐P65, MyD88, IL‐2, IL‐6, IL‐8, TNF‐a, PICP and PIIINP as well as enhanced macrophage infiltration, cardiomyocyte apoptosis. After treatment with tanshinone IIA combined with LPS for 4 weeks, the rats showed better condition than those treated with only LPS. These results indicate that tanshinone IIA attenuates MI and prevents left VR. Importantly, inhibition of TLR4/MyD88/NF‐κB signalling pathway is a key step in this process.

Tanshinone IIA Sodium sulfonate regulates antioxidant system, inflammation, and endothelial dysfunction in atherosclerosis by downregulation of CLIC1

BACKGROUND

Tanshinone IIA Sodium sulfonate (STS) is clinically used for treating cardiovascular diseases in Traditional Chinese Medicine due to its antioxidation and anti-inflammation activities. Intracellular chloride channel 1 (CLIC1) participates in the regulation of oxidative stress and inflammation. This study investigates whether CLIC1 mediates the cardioprotective effects of STS.

METHODS

STS were used to treat atherosclerosis (AS) induced by feeding Apolipoprotein E-deficient (ApoE^-/-) mice with a high-fat, cholesterol-rich diet. In addition, normal and CLIC1^-/- human umbilical vein endothelial cells were treated with STS after exposure to H₂O₂ for 12h. The oxidative status was determined by analyzing reactive oxygen species(ROS) and malondialdehyde (MDA) levels. ELISA, qRT-PCR and Western blot were used to determine the levels of TNF-α, IL-6, ICAM-1 and VCAM-1. CLIC1 cellular localization was examined by immunofluorescence. Chloride ion concentration was detected with chloride ion quenchers (MQAE).

RESULTS

STS treatment decreased atherosclerotic lesion area by 3.5 times (P = 0.001) in vivo. Meanwhile, STS reduced MDA production (13.6%, P = 0.008), increased SOD activity (113.6%, P = 0.008), decreased TNF-α (38.6%, P = 0.008) and IL-6 (43.0%, P = 0.03) levels, and downregulated the expression of CLIC1, ICAM-1, and VCAM-1 in the atherosclerotic mice. The dose-dependent anti-oxidative and anti-inflammatory effects of STS were further confirmed in vitro. Furthermore, CLIC1 depletion abolished the STS-mediated decrease of ROS and MDA production in HUVEC cells. Additionally, STS inhibited both CLIC1 membrane translocation and chloride ion concentration.

CONCLUSION

The anti-oxidant, and anti-inflammation properties of STS in preventing AS is mediated by its inhibition of CLIC1 expression and membrane translocation.

Traditional Chinese Medicine Protects against Cytokine Production as the Potential Immunosuppressive Agents in Atherosclerosis

Atherosclerosis is a chronic inflammatory disease caused by dyslipidemia and mediated by both innate and adaptive immune responses. Inflammation is a critical factor at all stages of atherosclerosis progression. Proinflammatory cytokines accelerate atherosclerosis progression, while anti-inflammatory cytokines ameliorate the disease. Accordingly, strategies to inhibit immune activation and impede immune responses towards anti-inflammatory activity are an alternative therapeutic strategy to conventional chemotherapy on cardiocerebrovascular outcomes. Since a number of Chinese medicinal plants have been used traditionally to prevent and treat atherosclerosis, it is reasonable to assume that the plants used for such disease may suppress the immune responses and the resultant inflammation. This review focuses on plants that have immunomodulatory effects on the production of inflammatory cytokine burst and are used in Chinese traditional medicine for the prevention and therapy of atherosclerosis.

Traditional Chinese medicine, Danlou tablets alleviate adverse left ventricular remodeling after myocardial infarction: results of a double-blind, randomized, placebo-controlled, pilot study

BACKGROUND

Danlou tablets, a patented Chinese Medicine, have been long approved for the treatment of ischemic heart disease in China. While numerous empirical observations suggested Danlou tablets could decrease frequency and duration of angina pectoris attacks, evidence supporting its efficacy on cardiac remodeling remains inadequate. Therefore, this pilot trial was designed to determine whether Danlou tablets would reduce adverse left ventricular (LV) remodeling in patients with myocardial infarction (MI).

METHODS AND RESULTS

Eligible patients with acute MI were enrolled and randomly assigned to Danlou tablets or placebo groups, superimposed on standard treatment for MI. Then, in addition to assessment of the clinical outcome, the changes in LV volumes were evaluated by a serial echocardiography. In total, 83 patients (Danlou tablets 42 and placebo 41) completed 90 days of treatment and had complete baseline and outcome data. Standard echocardiographic evaluations revealed significant differences in the change of LV end-diastolic volume index (LVEDVi) between group of patients treated with Danlou tablets and the placebo group (-4.49 ± 7.29 vs. -0.34 ± 9.01 mL/m2, P < 0.001). The reduction in LVEDVi was independent of beta-blocker, ACE inhibitors/ARBs use. Furthermore, treatment with Danlou tablets significantly reduced LV end-systolic volume index (-4.09 ± 5.85 vs. -0.54 ± 5.72 mL/m2, P < 0.001) and improved the LV ejection fraction (4.83 ± 9.23 vs. 0.23 ± 8.15 %, P < 0.001), as compared to placebo. Meaningfully, the incidence of the major adverse cardiovascular events was also lower in patients receiving Danlou tablets (P < 0.05).

CONCLUSION

Superimposed on the standard pharmacologic treatment, Danlou tablets significantly reversed post-MI adverse LV remodeling, thereby contributed to the overall positive clinical outcome.

TRIAL REGISTRATION

clinicaltrials.gov identifier NCT02675322 (February 1, 2016).