The Effect of Cardiac Rehabilitation on Ferroptosis in Patients With Coronary Artery Disease

Official title

Evaluation of Ferroptosis-Related Biomarkers in Individuals With Coronary Artery Disease: The Impact of Cardiac Rehabilitation

Overview

Coronary artery disease (CAD) remains a major global health concern and is the leading cause of cardiovascular mortality worldwide. Cardiac rehabilitation (CR) is a comprehensive, evidence-based intervention that integrates exercise training with optimal medical management and has been shown to improve clinical outcomes in patients with CAD. The primary objective of this study is to investigate the effects of cardiac rehabilitation on ferroptosis, an iron-dependent form of regulated cell death, in patients with coronary artery disease. A total of 90 participants will be enrolled in the study after providing written informed consent. The study population will consist of three groups: 30 patients with CAD who participate in a cardiac rehabilitation program, 30 patients with CAD who voluntarily decline participation in cardiac rehabilitation, and 30 age- and sex-matched healthy volunteers without any known chronic disease. Peripheral venous blood samples will be collected from patients undergoing cardiac rehabilitation both before the initiation of the rehabilitation program and upon its completion. A single blood sample will be obtained from patients who decline participation in cardiac rehabilitation and from healthy control participants. To evaluate ferroptosis-related molecular alterations, the expression levels of the ferroptosis-associated genes GPX4, SLC7A11, ACSL4, FSP1, NRF2, TFRC, and NCOA4 will be analyzed. In addition, serum concentrations of ferroptosis-related biomarkers, including free iron, 4-hydroxynonenal (4-HNE), malondialdehyde (MDA), and GPX4 protein, will be measured. The molecular and biochemical parameters will be compared among the three study groups, and changes in ferroptosis-related biomarkers before and after the cardiac rehabilitation program will be evaluated in patients undergoing cardiac rehabilitation.

Detailed description

Coronary artery disease (CAD) remains a major global public health challenge and is the leading cause of cardiovascular mortality worldwide. In recent years, ferroptosis, an iron-dependent form of regulated cell death, has emerged as a major focus of biomedical research. Characterized by excessive lipid peroxidation and the accumulation of reactive oxygen species (ROS), ferroptosis has provided new insights into the pathophysiology of CAD and represents a promising therapeutic target.

The pathophysiological significance of ferroptosis in cardiovascular diseases stems from its central role in dysregulated iron metabolism, lipid peroxidation, and excessive ROS accumulation. These mechanisms contribute substantially to the initiation and progression of CAD. Under pathological conditions such as ischemia and hypoxia, cardiomyocytes exhibit increased susceptibility to ferroptosis, leading to cellular dysfunction, myocardial injury, and impaired cardiac function.

Cardiac rehabilitation (CR) is a comprehensive, multidisciplinary intervention that integrates exercise training, cardiovascular risk factor management, lifestyle modification, and psychosocial support, and constitutes a cornerstone of contemporary CAD management. CR has been shown to slow or delay disease progression by targeting modifiable cardiovascular risk factors while improving quality of life, cardiac performance, exercise capacity, and cardiovascular symptoms. Furthermore, CR reduces anxiety, depression, and psychological stress, facilitates return to work, and promotes independence in activities of daily living.

Exercise-based cardiac rehabilitation is among the interventions supported by the strongest evidence for reducing mortality and morbidity in patients with CAD. Experimental studies in animal models have demonstrated that aerobic exercise suppresses ferroptosis, thereby reducing cardiomyocyte death, protecting the ischemic myocardium, and improving cardiac function. Conversely, induction of ferroptosis in cardiomyocytes has been shown to exacerbate ischemia-reperfusion injury. However, no clinical study has comprehensively investigated ferroptosis-related molecular alterations in patients with CAD or evaluated the effects of cardiac rehabilitation on these pathways in humans.

Therefore, the present study aims to compare ferroptosis-related molecular and biochemical biomarkers among patients with CAD undergoing cardiac rehabilitation, patients with CAD who voluntarily decline participation in cardiac rehabilitation, and healthy controls. In addition, changes in ferroptosis-related biomarkers before and after completion of the cardiac rehabilitation program will be evaluated in patients undergoing cardiac rehabilitation.

Interventions

• Behavioral Cardiac Rehabilitation
  A supervised, comprehensive cardiac rehabilitation program consisting of individualized aerobic and resistance exercise training, patient education, lifestyle modification, and cardiovascular risk factor management according to current clinical practice guidelines.

Primary outcome measures

• Change in GPX4 Gene Expression [Time frame: Baseline and immediately after completion of the cardiac rehabilitation program (6 weeks).]

Secondary outcome measures (9)

• Change in SLC7A11 Gene Expression [Time frame: Baseline and immediately after completion of the cardiac rehabilitation program (6 weeks)]
• Change in ACSL4 Gene Expression [Time frame: Baseline and immediately after completion of the cardiac rehabilitation program (6 weeks).]
• Change in FSP1 Gene Expression [Time frame: Baseline and immediately after completion of the cardiac rehabilitation program (6 weeks).]
• Change in NRF2 Gene Expression [Time frame: Baseline and immediately after completion of the cardiac rehabilitation program (6 weeks).]
• Change in TFRC Gene Expression [Time frame: Baseline and immediately after completion of the cardiac rehabilitation program (6 weeks).]
• Change in NCOA4 Gene Expression [Time frame: Baseline and immediately after completion of the cardiac rehabilitation program (6 weeks).]
• Change in Serum Free Iron Concentration [Time frame: Baseline and immediately after completion of the cardiac rehabilitation program (6 weeks).]
• Change in Serum 4-Hydroxynonenal (4-HNE) Concentration [Time frame: Baseline and immediately after completion of the cardiac rehabilitation program (6 weeks).]
• Change in Peak Oxygen Uptake (Peak VO₂) [Time frame: Baseline and immediately after completion of the cardiac rehabilitation program (6 weeks).]

Eligibility criteria

Inclusion criteria

Patients With Coronary Artery Disease (CAD):

• Age between 18 and 75 years.
• Diagnosis of coronary artery disease within the previous 3 months.
• Eligible to participate in a cardiac rehabilitation program or voluntarily decline participation in the cardiac rehabilitation program.
• Peak exercise capacity of ≥5 metabolic equivalents (METs).
• Able to undergo cardiopulmonary exercise testing (CPET).
• Able to understand the study procedures and provide written informed consent.

Healthy Controls:

• Age between 18 and 75 years.
• No history of coronary artery disease or other cardiovascular diseases.
• No history of chronic systemic diseases, including diabetes mellitus, hypertension, chronic kidney disease, chronic liver disease, inflammatory or autoimmune diseases, or malignancy.
• Not receiving regular medication.
• Able to provide written informed consent.

Exclusion criteria

Patients With Coronary Artery Disease (CAD):

• Decompensated heart failure.
• Unstable angina pectoris.
• Uncontrolled or complex ventricular arrhythmias.
• Severe pulmonary hypertension.
• Neurological, orthopedic, or musculoskeletal disorders limiting exercise performance.
• Absolute contraindications to cardiopulmonary exercise testing or cardiac rehabilitation according to current clinical guidelines.
• Chronic kidney failure or chronic liver disease.
• Active infection.
• Active inflammatory or autoimmune disease.
• Active malignancy or history of malignancy.
• Pregnancy.
• Cognitive or psychiatric disorders that would interfere with study participation or protocol compliance.

Healthy Controls:

• History of coronary artery disease or other cardiovascular diseases.
• History of chronic systemic diseases, including diabetes mellitus, hypertension, chronic kidney disease, chronic liver disease, inflammatory or autoimmune diseases, or malignancy.
• Regular medication use within the previous 6 months.
• Active infection.
• Pregnancy.
• Age younger than 18 years or older than 75 years.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: Yes

Study design

Allocation

Non-randomized

Model

Parallel assignment

Masking

Open label

Primary purpose

Treatment

Study locations

Turkey (Türkiye) · 1 center

• Erciyes University Faculty of Medicine — Kayseri

Publications

• Rao X, Huang X, Zhou Z, Lin X. An improvement of the 2^(-delta delta CT) method for quantitative real-time polymerase chain reaction data analysis. Biostat Bioinforma Biomath. 2013 Aug;3(3):71-85. PMID 25558171
• Cai W, Liu L, Shi X, Liu Y, Wang J, Fang X, Chen Z, Ai D, Zhu Y, Zhang X. Alox15/15-HpETE Aggravates Myocardial Ischemia-Reperfusion Injury by Promoting Cardiomyocyte Ferroptosis. Circulation. 2023 May 9;147(19):1444-1460. doi: 10.1161/CIRCULATIONAHA.122.060257. Epub 2023 Mar 29. PMID 36987924
• Srichaiyapol O, Saiboonjan B, Ngernpimai S, Ponsue C, Sa-Ingthong N, Thongmee P, Wonglakorn L, Sukkasem C, Kendal RP, Daduang J, Tavichakorntrakool R, Srisrattakarn A, Chanawong A, Wongwattanakul M, Lulitanond A, Tippayawat P. Enhanced performances of the short-PCR coupled lateral flow assay in the detection of Candida albicans in clinical blood samples. Asian Pac J Allergy Immunol. 2025 Jun 22. d PMID 40544374
• Han J, Lin L, Fang Z, Xu D, Wang L, Ye B, Han X, Long X, Min J, Wu G, Liang G, Wang Y. Cardiomyocyte-derived USP13 protects hearts from hypertrophy via deubiquitinating and stabilizing STAT1 in male mice. Nat Commun. 2025 Jul 1;16(1):5927. doi: 10.1038/s41467-025-61028-1. PMID 40593642
• Piepoli MF, Corra U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, McGee H, Mendes M, Niebauer J, Zwisler AD, Schmid JP; Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Associ PMID 19952757
• Verdonk ML, Ludlow RF, Giangreco I, Rathi PC. Protein-Ligand Informatics Force Field (PLIff): Toward a Fully Knowledge Driven "Force Field" for Biomolecular Interactions. J Med Chem. 2016 Jul 28;59(14):6891-902. doi: 10.1021/acs.jmedchem.6b00716. Epub 2016 Jul 7. PMID 27353137
• Anderson L, Thompson DR, Oldridge N, Zwisler AD, Rees K, Martin N, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2016 Jan 5;2016(1):CD001800. doi: 10.1002/14651858.CD001800.pub3. PMID 26730878
• Zhang Z, Tang J, Song J, Xie M, Liu Y, Dong Z, Liu X, Li X, Zhang M, Chen Y, Shi H, Zhong J. Elabela alleviates ferroptosis, myocardial remodeling, fibrosis and heart dysfunction in hypertensive mice by modulating the IL-6/STAT3/GPX4 signaling. Free Radic Biol Med. 2022 Mar;181:130-142. doi: 10.1016/j.freeradbiomed.2022.01.020. Epub 2022 Feb 2. PMID 35122997

Identifiers

NCT: NCT07722637 · 2025/489 · TTU-2025-15709

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗