Therapeutic potentials and mechanisms of the Chinese traditional medicine Danshensu

Journal Pre-proof Therapeutic potentials and mechanisms of the Chinese traditional medicine Danshensu Jinli Zhang, Qianqian Zhang, Guang Liu, Ning Zhang PII:

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Please cite this article as: Zhang, J., Zhang, Q., Liu, G., Zhang, N., Therapeutic potentials and mechanisms of the Chinese traditional medicine Danshensu, European Journal of Pharmacology (2019), doi: https://doi.org/10.1016/j.ejphar.2019.172710. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier B.V.

Therapeutic potentials and mechanisms of the Chinese traditional medicine Danshensu Jinli Zhanga, Qianqian Zhangb, Guang Liua, Ning Zhanga

a

Department of Cardiology, The Fourth Affiliated Hospital of Hebei Medical University, 12

Health Road, Shijiazhuang, Hebei 050011, PR China b

Department of Basic Medicine, Hebei Medical University, 361 Zhongshan East Road,

Shijiazhuang, Hebei 050017, P. R. China

Correspondence: Dr. Ning Zhang, Department of Cardiology, The Fourth Affiliated Hospital of Hebei Medical University, 12 Health Road, Shijiazhuang, Hebei 050011, PR China; Email address: [email protected], Tel: 15831183886

Disclaimer: The authors declare no competing financial interest.

Abstract

Danshensu is a pure molecule derived from Danshen, which is the root of the herb Salvia miltiorrhiza. It has a clearly defined chemical structure and demonstrates therapeutic effects in cardiovascular diseases (e.g., myocardial ischemia and reperfusion, atherosclerosis, hypertension), cerebral lesions and disorders (e.g., ischemia, cognitive decline, and anxiety), and other health problems (e.g., thrombosis, tumorigenesis, pancreatitis). The mechanisms behind these effects include antioxidation, anti-apoptosis, vasodilation, inflammation regulation, lipidemia control, etc., through the PI3K/Akt-ERK1/2/Nrf2/HO-1, Bcl-2/Bax, eNOS and other molecular signaling pathways. Both Danshen and Danshensu might be more effective than classical cardiovascular drugs, and their combination yields improved therapeutic efficiency. Here, we provide an overview of these drugs for a better understanding of Danshensu as a promising Chinese traditional medicine.

Key words: Dashensu; Chinese traditional medicine; Cardiovascular disease; Antioxidiation; Anti-apoptosis

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1. Introduction The awarding of the 2015 Nobel Prize for the discovery of artemisinin (Qinghaosu) to Dr. Youyou Tu was a major milestone in the medical history of China, which has attracted global curiosity in traditional Chinese medicine (Su and Miller, 2015, White, 2008). Danshen is one of the major traditional medicines and has been widely used for more than a thousand years in China. This product is extracted from the dried root of Salvia miltiorrhiza Danshensu and has been used in treating cardiovascular, cerebral, thrombotic, and other types of diseases (Cheng, 2006, Maione and Mascolo, 2016, Su et al., 2015). Searching the major Chinese science publication database (http://www.cnki.net/) yields nearly 50,000 results, and PubMed currently has more than 3000 reports about "Danshen". To date, more than 900 Danshen-related drugs have been approved by the National Medical Products Administration of China, a government department similar to the American FDA. In addition, Danshen-related supplements are also available in herb shops in America and Japan (Zhou et al., 2005). Danshensu, also called Salvianic aid A, is extracted from Danshen (Bao et al., 2018). Unlike Danshen, which is a complex mixture with many unidentified chemical components (Pang et al., 2016, Zhong et al., 2009, Zhou et al., 2005), Danshensu is a purified compound with a clearly defined structure, thus allowing it to be manufactured for extensive research use. Danshensu [3-(3, 4-dihydroxy-phenyl) lactic acid] is structurally composed of a catechol and a lactic acid (Figure 1). The catechol is the major active group that exerts an antioxidation effect for the protection of cardiac I/R injury (Jun-peng Li et al., 2014).

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For more therapeutic effects and better efficiency, chemical modifications have been extensively made through asymmetric synthesis (Cui et al., 2014, Dong et al., 2009, Jia et al., 2012a), and the full list of Danshensu derivatives has been summarized (Bao et al., 2018). Many of them have demonstrated improved drug efficacy. For example, in the report by Cui, tetramethylpyrazine (TMP) was esterized onto Danshensu, together with acetylation of three hydroxyl groups, to generate the final product ADTM (Cui et al., 2013). In H9c2 cardiomyoblast cells treated with t-butylhydroperoxide (BHP), Danshensu increased the cell viability from ~10% to ~30%, and ADTM further boosted it to ~90%, which remarkably rescued the cells from the BHP-induced oxidative stress. New DSS and TMP conjugates have demonstrated even better efficacy than ADTM (Wang et al., 2017). Efforts in the search for greater DSS derivatives are still continuing (Li et al., 2016). Compared to Danshen, Danshensu is 13 times more potent in dilating 5-HTprecontracted coronary artery rings (IC50: 71.5 ± 11.0 µg/ml vs. 930.3 ± 133.5 µg/ml) (Lam et al., 2007). In this study, 0.2 mg/ml Danshensu was able to relax the CaCl2induced vasoconstriction, while it took 2 mg/ml Danshen aqueous extract to achieve the similar effect. In addition, 0.6 mg/ml Danshensu abolished the KCl-induced vasoconstriction, but this effect required 10 mg/ml Danshen aqueous extract to achieve the similar effect. Extensive studies have demonstrated its therapeutic effects and potential mechanisms in cardiovascular diseases, cerebral lesions, coagulation imbalances, and other common health problems. Here, we briefly review these in order to draw more

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global attention to Danshensu as another promising drug derived from Chinese traditional medicine for the health of humankind.

2. Treatment of diseases 2.1 Cardiovascular diseases 2.1.1 Myocardial ischemia and reperfusion Acute myocardial infarction is one of the threats to human life, afflicting more than 15.9 million people worldwide (GBD 2015 Disease and Injury Incidence and Prevalence Collaborators, 2016). This devastating event, also called a heart attack, is basically caused by insufficient blood flow to the heart due to atherosclerosis, spasm of coronary arteries, or other conditions that fail to meet the oxygen and nutrient needs of the heart. This medical event is usually experienced in two sequential phases: ischemia (during which necrosis, apoptosis and autophagy occur) and reperfusion (during which further damage might be incurred) (Heusch and Gersh, 2017). The protective effect of Danshensu on myocardial ischemia and reperfusion (I/R) was extensively studied. In the rat model of myocardial I/R-induced injury, Danshensu treatment significantly reduced the myocardium infarct sizes by 25% and 50% in a dosedependent manner (Yin et al., 2013). Meanwhile, the levels of serum biomarkers (CKMB, cardiac troponin I, and LDH) of myocardial infarction were also decreased. Similar cardioprotective effects of Danshensu were also seen in other reports (Bao et al., 2018, Li et al., 2012, Tang et al., 2011a, Wu et al., 2007). Danshensu exerts its cardioprotective effects mainly through two mechanisms: antioxidation and antiapoptosis. The oxidative stress due to excessive ROS production

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is one of the major mechanisms involved in the myocardial I/R injury (Hausenloy and Yellon, 2015, 2016). Danshensu was able to scavenge ROS and boost the activities of endogenous antioxidants, such as SOD, CAT (catalase), GSH-PX (glutathione peroxides) and heme oxygenase-1 (HO-1), by activating the nuclear factor erythroid-2related factor 2 (Nrf2) pathway through Akt/ERK1/2 signaling (Cui et al., 2013, Hu et al., 2016, Yin et al., 2013, Yu et al., 2015). In addition to antioxidation, Danshensu increased the viability of cells that received I/R insults and reduced LDH release due to cell damage (Yin et al., 2013). This effect was further confirmed in this study by flow cytometric analysis based on the expression of annexin V and PI as well as the TUNEL assay, in which Bcl-2/Bax might have played a critical role. The Bax protein is mainly in the cytosol under normal conditions, but it can, upon stress, translocate onto the mitochondrial membrane to initiate apoptosis. Bcl-2 binds Bax to sequester its apoptotic activity. In the rats that received the I/R procedure, Danshensu treatment reduced Bax, while it increased Bcl-2 protein expression levels in the heart tissue, thus inhibiting apoptosis for cardioprotection (Guo et al., 2015). Danshensu might also exert antiapoptosis through the mTOR pathway. mTOR is a member of the phosphatidylinositol 3-kinase-related kinase family and regulates most major cellular functions, including cell growth and proliferation (Laplante and Sabatini, 2012). Research has shown that mTOR overexpression in the heart remarkably protected against I/R injury and suppressed the inflammatory response in rats (Aoyagi et al., 2012). When Danshensu was added to cultured neonatal rat cardiomyocytes that had received I/R stress, survival of these cells were significantly improved. More importantly, mTOR signaling was activated (as indicated by phosphorylation of S6K and

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S6), concomitant with decreased autophagy flux and expression of autophagy and apoptosis biomarkers (p62, LC3-II, beclin-1, Bax, and caspase-3) (Fan et al., 2016). One study also suggested that Danshensu might attenuate apoptosis in I/R rat hearts by reducing calcium overload via the p-JNK-NF-κB-TRPC6 pathway (Meng et al., 2016a). The activity of vasorelaxation is also involved in the protective effect of Danshensu against myocardial ischemia, and this effect is mediated through the inhibition of calcium influx in the vascular smooth muscle cells, the increase of eNOS activity and NO generation (Lam et al., 2007, Xiao-Yong LE et al., 2009). Overall, the therapeutic effects and mechanisms of Danshensu on the protection against myocardial ischemic injury have been extensively studied in animal and cell culture studies, which are well summarized in a review (Bao et al., 2018). In the 27 listed animal studies, most of which were rats, the myocardial infarct sizes of these animals were almost all reduced by Danshensu and levels of the related biomarkers (e.g., CK, SOD, LDH, etc.) were largely improved. For example, in one study, Danshensu significantly reduced the infarct size of the rat hearts from 43.29 ± 5.86% to 34.90 ± 9.15% at 1 µM and further down to 24.00 ± 6.35% at 10 µM (Yu et al., 2015). The reactive oxygen species (ROS) related biochemical markers in the heart homogenate were also restored, as SOD was increased from ~100 U under the I/R treatment to ~125 U per mg protein by Danshensu at 1 µM and further restored up close to the normal level (~150 U per mg protein) at 10 µM. In the 16 reported cell studies, all used cell viability and apoptosis-related molecules and pathways to analyze the protective effect of Danshensu. For example, in the study

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by Hu, Danshensu significantly restored the viability of H9c2 cardiomyocytes treated with hypoxia/reoxygenation injury in a dose-dependent manner, with a remarkable reduction in LDH release (Hu et al., 2016). Further investigation revealed an increased Bcl-2/Bax ratio and decreased expression of cleaved caspase-3, indicating an alleviation of apoptosis. This effect was later demonstrated to be through the Akt/Nrf2/HO-1 signaling pathway. 2.1.2 Atherosclerosis Atherosclerosis is the most common cause of vascular disease worldwide (Herrington et al., 2016) and is characterized by abnormal subendothelial accumulation of excess fatty plaques inside the blood vessels, with the hallmarks of endothelial cell dysfunction and inflammation (Gimbrone Jr and García-Cardeña, 2016, Gisterå and Hansson, 2017). Danshensu prevents atherosclerosis mainly through three major mechanisms: endothelial protection, macrophage regulation, and lipidemia control. Evidence has shown that Danshensu is able to prevent atherosclerosis. In the animal model, in which the rats were fed a methionine-rich diet and thus developed atherosclerotic lesions in the intima of descending aorta, the oral administration of Danshensu in these rats significantly reduced the number of foamy cells in the affected area (Yang et al., 2010). Further examination of these rats showed that Danshensu treatment reduced the serum level of homocysteine, a well-established inducer of atherosclerosis that exerts deleterious effects on endothelial cells. Additionally, possibly due to the endothelial protection of Danshensu, the serum levels of endothelin were reduced while the serum levels of NO were increased in these rats.

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In addition to the animal studies, the endothelial protective effect of Danshensu was directly demonstrated in a cultured endothelial cell line (CRL-1730) (Yang et al., 2009). When these cells were treated with H2O2 to induce oxidative stress, a biological process as a mechanism in the pathology of atherosclerosis, Danshensu treatment significantly restored cell viability in a dose-dependent manner through the inhibition of apoptosis. In addition to the anti-apoptosis, further study revealed that Danshensu reduced the expression of CD40, which is a well-known key inflammatory molecule in the development of atherosclerosis. Similar protective effects were seen with respect to homocysteine-induced dysfunction in endothelial cells (Chan et al., 2004). Danshensu also exerts protection against atherosclerosis through the regulation of macrophages. Macrophages are key integrators of inflammatory and metabolic signals and play an essential role in the pathogenesis of atherosclerosis (Moore et al., 2013, Tabas and Lichtman, 2017). In mouse macrophages (Raw264.7), which were induced into foam cells by oxidized LDL, Danshensu treatment lowered the intracellular accumulation of lipid droplets (Gao et al., 2016). This effect was largely mediated by reducing the expression of scavenger receptor CD36 and its orthologue SR-BI and, more importantly, by increasing the cellular cholesterol exporters ABCA1 and ABCG1. In addition to a cholesterol efflux acceleration effect, Danshensu directly inhibits the secretion of TNF, IL-1, IL-6 and IL-8, suppressing the inflammatory activation of macrophages (Wenjun Wang and Zhi Yao, 1995). It is notable that Danshensu attenuates atherosclerosis also by controlling lipid metabolism, as it eliminated excess cholesterol and effectively controlled hyperlipidemia in rats. This is probably through the

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inhibition of FAS and HMGR, two critical enzymes involved in lipid biochemical synthesis (Chen et al., 2015). 2.1.3 Hypertension and pulmonary hypertension Hypertension is the medical condition of elevated blood pressure and is a global public health challenge (Kearney et al., 2005). More than 90% of cases are primary hypertension with an unknown etiology. In spontaneously hypertensive rats, intraperitoneal administration of Danshensu significantly reduced systolic and diastolic blood pressures of rats by up to 20% (Tang et al., 2011b). Similar results were seen when Danshensu was used in combination with another common Chinese traditional medicine, Gegen (Ng et al., 2011, Zhang et al., 2013). In addition to the vasorelaxation effect, Danshensu also lowers blood pressure through inhibition of vascular remodeling (Zhang et al., 2016). It is interesting that Danshensu also exerted protection in pulmonary hypertension. In rats with pulmonary hypertension induced by hypobaric hypoxia for 4 weeks, Danshensu treatment significantly decreased the right ventricle systolic pressure, hypertrophy, and pulmonary vascular remodeling index (Zhang et al., 2018). Further investigation in this study indicated that this effect might be mediated through TGF-βSmad3 signaling, an important pathway involved in cell proliferation that accounts for pulmonary artery restriction and remodeling (Meng et al., 2016b). 2.1.4 Angina pectoris

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Danshen, from which Danshensu is extracted, has been traditionally used to treat angina pectoris in China (Zhou et al., 2005). Some studies have indicated that it might even be more effective than the classical isosorbide dinitrate (Jia et al., 2012b, Luo et al., 2015). It has been suggested that Danshensu is the major component that accounts for this therapeutic effect through vasorelaxation (Zhou et al., 2012). This effect involves the inhibition of the calcium channel in vascular smooth muscle cells and the increase of COX-2 and prostacyclin expression in endothelial cells (Lam et al., 2007, Li et al., 2015, Wang et al., 2013). Nevertheless, it might also include the mechanisms of actions on vascular endothelial protection in the treatment of myocardial ischemia and hypertension by Danshensu (Tang et al., 2011a, Yang et al., 2010). 2.1.5 Myocardial hypertrophy Pathological myocardial hypertrophy often causes heart failure, arrhythmias and sudden death. This process of abnormal heart enlargement often involves cell proliferation, oxidative stress, inflammation, angiogenesis, etc. (Nakamura and Sadoshima, 2018, Shimizu and Minamino, 2016). It is usually triggered by angiotensin II, endothelin, catecholamines, mechanic forces, and ANP or BNP through PLC, MAPK, NFAT, CAMKII, PKC, mTOR and other corresponding intracellular signaling pathways (Heineke and Molkentin, 2006, Tham et al., 2015). In rats with cardiac hypertrophy induced by isoproterenol treatment, Danshensu administration significantly reduced the heart and the left ventricular weight in a dosedependent manner as well as lowered the incidences of ventricular tachycardia and ventricular fibrillation (Tang et al., 2011c, a). Further investigation revealed that

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Danshensu decreased malondialdehyde and increased the activity of SOD in serum, which is suggestive of an inhibitory effect on oxidative stress. In addition, Danshensu restored the expression of the protein Cx43 in the left ventricle, which is a major protein of the gap junction in rat ventricular myocardium and involved in arrhythmogenesis (Wang and Hill, 2010). In addition, Danshensu could also protect against cardiac hypertrophy by inhibiting ANP expression induced by angiotensin II in myocardial cells (Guo et al., 2005). Nevertheless, the mechanism of the protection from cardiac hypertrophy provided by Danshensu is certainly related to its anti-hypertensive effect. 2.1.6 Cardiac fibrosis It is notable that Danshensu could inhibit cardiac fibroblast proliferation and collagen I synthesis in rats with cardiac fibrosis induced by the treatment of isoproterenol via suppression of the ROS-p38 MAPK cellular pathway (Lu et al., 2014). 2.2 Cerebral diseases 2.2.1 Cerebral ischemia Cerebral ischemia is the condition of insufficient blood supply to brain tissue to meet its oxygen and nutrient demand, resulting in death or permanent neurological impairment (Gidday, 2006). This disease causes 44 million physical disabilities and 5.5 million deaths each year worldwide. This condition induces excitotoxicity, oxidative and nitrative stress as well as inflammation that leads to apoptosis, necrosis, and other types of cell death (Khoshnam et al., 2017).

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In addition to the antioxidation and anti-apoptosis effects that were discussed previously in the treatment of myocardial ischemia and reperfusion, Danshensu protects against cerebral ischemia mainly through another unique mechanism. P-glycoprotein (encoded by the multidrug resistance gene) is the efflux pump expressed in endothelial cells at blood-brain barrier sites and is responsible for the transport of metabolites and drugs out of cells (Huang et al., 2019, Schinkel, 1999). Research has shown that Danshensu can cross the blood-brain barrier, and P-glycoprotein determines the transportation and distribution of Danshensu in brain tissue (Yu et al., 2011). During cerebral ischemia, the expression of P-glycoprotein was reduced by approximately 50%. Even more interestingly, treatment with Danshensu further reduced P-glycoprotein by more than two-fold (Chong et al., 2012). 2.2.2 Cognitive improvement Cognitive impairment is caused by neurodegeneration due to alcohol and drug use, brain trauma, aging, neurological disorders, and other abnormal medical conditions, in which inflammation plays a critical role (Glass et al., 2010, Pandharipande et al., 2013, Shih et al., 2013). One of the most common causes of cognitive deficits is diabetes (Geijselaers et al., 2015), and this is related to the increased generation of advanced glycation end products, which can elicit deleterious inflammation (Ramasamy et al., 2005). The treatment of diabetes-related cognitive impairment with Chinese traditional herbs has a long history, and their beneficial effects on this clinical complication is widely reported (Seto et al., 2015, Xu et al., 2013, Zhou et al., 2016).

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In rats with diabetes introduced by intraperitoneal injection of streptozotocin (a chemical agent that kills the insulin-producing beta cells of the pancreas), Danshensu treatment rescued these rats from the cognitive decline resulting from diabetes (Wang et al., 2012). Further analysis revealed Danshensu suppressed the increase in the expression of RAGE, p-p38, and COX-2 and the activation of NF-κB pathway as well as the increase of TNF-α, IL-6, and PGE2 levels in the hippocampus. These observations suggest that Danshensu has a potential therapeutic effect on cognitive improvement through the inhibition of neuroinflammation. In addition to cognitive protection, Danshensu also has an anxiolytic-like effect in rats through the dopaminergic signaling pathway (Kwon et al., 2014). 2.3 Other clinical complications Danshensu has also been demonstrated to have an anticoagulation effect. In the rat model, it significantly reduced thrombus formation through a dose-dependent inhibition of ADP and arachidonic acid-induced platelet aggregation as well as blood viscosity. These effects were then found to be attributed to its highly selective inhibition of COX-2 and its ability to normalize the balance between thromboxane A2 and prostacyclin (Yu et al., 2014). With regard to anti-tumor effect, Danshensu inhibited the invasion and migration of B16F10 melanoma cells in a dose-dependent manner and dramatically inhibited VEGFinduced endothelial migration and other tumor-related biological processes. In rats, Danshensu inhibited the lung metastasis of the B16F10 melanoma cells, further confirming its anti-tumor effect (Zhang et al., 2010a).

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In addition, Danshensu might also be therapeutically useful for dealing with pancreatitis and preeclampsia through anti-inflammation, antioxidation, anti-apoptosis, and other mechanisms that have been discussed previously (Shen et al., 2011, Wang et al., 2010). 2.4. Danshen and Danshensu versus classical cardiovascular drugs Danshen and Danshensu have also been compared to other classical drugs for cardiovascular diseases. In a recent study by Lin et al., Danshen Dripping Pills, one of the most prevalent Danshen-related medicines, have achieved a better clinical symptom relief rate (96.97% vs 84.85%) and ECG improvement rate (95.45% vs 83.33%) than isosorbide dinitrate, with fewer side effects (6.06% vs 18.18%), in the treatment of acute angina pectoris (Lin and Li, 2019). Similar results have been reported in other clinical studies (Li, 2016, Zhang, 2016). Moreover, a systematic review suggested the possibility of better clinical efficacy with Danshen in acute myocardial infarction, heart failure, and recurrence of angina as compared with classical cardiovascular drugs (Luo et al., 2013). In addition, the meta-analysis suggests that Danshen compounds and propranolol have similar therapeutic efficiency on heart failure, while Danshen is better at improving the left ventricular ejection fraction as compared with propranolol and other common drugs. Danshen and Danshensu are also administered in combination with these classical cardiovascular drugs. The combination of Danshensu with metoprolol achieved much greater efficiency in treating hypertension (91.66% vs 83.33%) and heart failure (90% vs 62%) as compared with metoprolol alone (Tang, 2009, Yang and Zhang, 2015). Treatment with nicardipine together with Danshen also more effectively controlled hypertension in pregnant patients and improved pregnancy outcomes through the

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mechanisms of anticoagulation, endothelial protection and blood lipid regulation (92.3% vs 74.4%)(Pu et al., 2018). In addition, co-treatment with perindopril, benazepril and Danshen preparations significantly improved the efficiency in alleviating renal damage (94.87% vs 74.36%) and diabetes (96.7% vs 76.7%) in hypertensive patients, with fewer side effects than either perindopril or benazepril alone (Fei, 2015, Huang and Zhong, 2015). Taken together, these lines of evidence suggest the therapeutic potential of Danshen and Danshensu on cardiovascular diseases, especially when used in combination with other classical drugs. Nevertheless, much more stringent and larger scale clinical studies are required to confirm this convincingly.

3. Discussion Here, we have provided an overview of the therapeutic effects of Danshensu on major clinical diseases and the underlying mechanisms, which are summarized in Table 1. However, Danshensu is certainly not a miracle medicine that cures every disease. It is notable that many of the reports about Danshensu lack scientific rigor in their studies, as the data seem less stringent and thus the conclusions seem suspicious and sometimes controversial (Hu et al., 2012, Lam et al., 2007, Zhang et al., 2010b). Only after the potential therapeutic target of Danshensu is clearly identified, experimentally validated, and followed by well controlled clinical trials (Chen and Ren, 2014) can the therapeutic effects of Danshensu be recognized and eventually accepted. Nevertheless, as a

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Chinese traditional medicine that has been used for about a thousand years, Danshensu will surely be another valuable therapeutic approach to resolving human health problems. Acknowledgment: This work was supported by the Project of Scientific Research of Hebei Provincial Administration of Traditional Chinese Medicine [2019134] and the Key Project of Medical Science Research of Hebei Province [20180594].

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Figure 1. Chemical structure of Danshensu.

Table 1. The major diseases treated by Danshensu and the involved mechanisms.

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Table 1. The major diseases treated by Danshensu and the involved mechanisms. Disease

Biological processes

Molecular mechanisms

Reference

PI3K/Akt-ERK1/2/Nrf2/HO-1 Bcl-2/Bax mTOR signalling Reducing calcium overload through p-JNK-NF-κB-TRPC6 Increases endothelin and NO Stimulates eNOS

Yu et al, 2015 Yin et al, 2013 Fan et al, 2016 Meng et al, 2016 Yang et al, 2010 Tang et al, 2011

Downregulates CD40 expression and exerts anti-apoptosis Reduces serum homocysteine Inhibits secretiion of TNF, IL-1, IL-6, IL-8 Promotes Cholesterol Efflux in Macrophages Reduces total glycerol, cholesterol, LDL-C and arteriosclerosis index Inhibits FAS and HMGR Increases CPT1 and HMGR

Yang et al, 2009 Chan et al, 2004 Wang et al, 1995 Gao et al, 2016 Chen et al, 2015 Chen et al, 2015 Chen et al, 2015

Cardiovascular diseases Myocardial ischemia and reperfusion Anti-oxidation Anti-apoptosis

Vasodilation

Atherosclerosis

Endothelial protection Macrophage regulation Lipidemia control

Hypertension

Vasorelaxation Reduces vascular remodeling

Zhang et al, 2016 Zhang et al, 2018

Pulmonary hypertension

Antioxidation

Regulates transforming growth factor-β-smad3

Meng et al, 2016a

Angina Pectoris

Vasodilation

Inhibition of calcium channel influx Regulates COX/PGI2 pathway

Lam et al, 2007 Wang et al, 2013

Myocardial hypertrophy

Anti-oxidation Restores Connexin 43 expression ANP expression inhibition

Increases superoxide dismutase (SOD)

Hu et al, 2016 Tang et al, 2011 Guo et al, 2005

Cardiac fibrosis

Inhibits cardiac remodeling

Regulates ROS-p38 MAPK signaling

Lu et al, 2014

Cerebral ischemia

Anti-oxidation Anti-apoptosis Easier blood-brain barrier crossing Neuroinflammation reduction Neurotoxicity reduction

Reduces P-glycoprotein expression during brain ischemia

Guo et al, 2015 Chong et al, 2011

Reduces advanced glycation end product

Ramasamy et al, 2005

Cerebral diseases

Cognitive improvement

Anxiolytic

Dopaminergic system enhancing

Monoamine oxidase inhibition

Kwon et al, 2014

Anticoagulation

Platelet aggregation inhibition

Yu et al, 2014

Tumor suprression

Angiogenesis inhibition Cell growth and proliferation inhibition Intestinal barrier protection, inflammation control, Anticoagulation

Inhibits COX-2 and modula tes the balance between thromboxane A2 and prostacyclin. Suppresses the MMP-2, -9 and VEGF expression Potential target of H-Ras

Other

Pancreatitis Preeclampsia

Zhang et al, 2010a Chen et al, 2014 Wang et al, 2010 Shen et al, 2011