# Idebenone attenuates ferroptosis by inhibiting excessive autophagy via the ROS-AMPK-mTOR pathway to preserve cardiac function after myocardial infarction Researcher: Ge Zhang Chinese name: 张格 ORCID identity anchor: https://orcid.org/0000-0002-3116-3246 Canonical researcher: https://drgezhang.com/#person Journal: European Journal of Pharmacology Year: 2023 Type: Article DOI: 10.1016/j.ejphar.2023.175569 Canonical page: https://drgezhang.com/papers/idebenone-ferroptosis.html Markdown record: https://drgezhang.com/papers/idebenone-ferroptosis.md ## Full Authors 1. Demin Li 2. Ge Zhang 3. Zeyu Wang 4. Jiacheng Guo 5. Yu Liu 6. Yongzheng Lu 7. Zhen Qin 8. Yanyan Xu 9. Chang Cao 10. Bo Wang 11. Qianqian Guo 12. Yunzhe Wang 13. Guozhen Liu 14. Xiaolin Cui 15. Jinying Zhang 16. Junnan Tang ## Official Abstract Cardiovascular diseases (CVDs) are the leading causes of mortality worldwide. As a type of CVDs, myocardial infarction (MI) induces ischemia hypoxia, which leads to excessive reactive oxygen species (ROS), resulting in multiple cell deaths and contributing to the subsequent development of heart failure or premature death. Recent evidence indicates that ROS-induced lipid peroxidation promotes autophagy and ferroptosis, leading to the loss of healthy myocardium and resulting in the dysfunction of cardiac tissue. Theoretically, cardiac function would be preserved after MI by inhibiting autophagy and ferroptosis. As an analog of coenzyme Q10 (CoQ10) and a clinically approved drug, idebenone would be used to inhibit ferroptosis and preserve cardiac function due to its capacity to improve mitochondrial physiology with antioxidant and anti-inflammatory properties. Here, we confirmed that the addition of idebenone inhibited H2O2-induced and RSL3-induced ferroptosis. Furthermore, the ROS-AMPK-mTOR pathway axis was identified as the signaling pathway that idebenone stimulated to prevent excessive autophagy and consequent ferroptosis. In the MI animal model, idebenone demonstrated a cardioprotective role by regulating ROS-dependent autophagy and inhibiting ferroptosis, which paves the way for the future clinical translation of idebenone in MI management. Text reproduced verbatim from PubMed indexed abstract ([source](https://pubmed.ncbi.nlm.nih.gov/36740037/)); [DOI](https://doi.org/10.1016/j.ejphar.2023.175569); [CC-BY-4.0](https://creativecommons.org/licenses/by/4.0/). ## Research & review context ### Research fields - Myocardial injury research - Regulated cell death in cardiovascular disease ### Review topics - Ferroptosis and autophagy in myocardial infarction - Preclinical cardioprotection and intervention timing ### Scientific role Cellular and mouse intervention study of idebenone-associated myocardial injury reduction and pathway-related evidence. ### Evidence position Preclinical experiments with pretreatment-containing regimens; not evidence of post-infarction-only clinical rescue, human safety or human survival benefit. ### Related concepts - Redox-related cardiac injury - Pretreatment-to-clinical translation ### Possible citation contexts - Background: regulated cell-death processes in myocardial injury. - Experimental evidence: ferroptosis- and autophagy-related cardioprotection, with dosing timing and alternative mechanisms retained. Possible literature-review contexts, not evidence of existing citations. Read the findings and Evidence Scope before citing the original article. ## Evidence Scale **Idebenone attenuates ferroptosis by inhibiting excessive autophagy via the ROS-AMPK-mTOR pathway to preserve cardiac function after myocardial infarction** H9c2 injury models, pharmacologic pathway probes and LAD-ligation mouse experiments provide preclinical functional and mechanism-supporting evidence for idebenone. The animal regimen included pretreatment; these findings do not establish post-infarction-only rescue treatment or human MI efficacy, safety or approval. | Evidence | Value | | --- | --- | | Cellular systems | H9c2 H2O2/RSL3 experimental systems | | Three main mouse groups | sham+vehicle; MI+vehicle; MI+idebenone | | Fig. 8 echocardiography/histology | Reported n=5 | | Cell/protein experiments | Reported n varies by assay; not summed into a total animal count | ### Counting note Figure-level n is the reported unit for the corresponding experiment, not a study-wide deduplicated total. Cells, technical readouts and animals cannot be added together. This synthesis focuses on the reviewed core cellular and animal experiments; public-omics background analyses are not human drug-validation cohorts. ## Research Question What cellular and mouse evidence supports idebenone-associated reduction of ferroptotic injury, and how does pretreatment timing limit translation to post-infarction clinical treatment? ## Author Evidence Summary This preclinical study used H9c2 injury models, pharmacologic pathway probes and LAD-ligation mouse experiments. Oxidative-injury, ferroptosis and autophagy readouts are distinguished from cardiac-function readouts. The animal regimen included dosing before surgery and is not evidence for treatment initiated only after infarction. The findings do not establish human myocardial-infarction efficacy, safety or an approved clinical indication. ## Key Findings ### KF1: Idebenone pretreatment reduced reported H2O2-associated injury in H9c2 cells, assessed using cell viability, ROS and lipid-peroxidation readouts. Context: H2O2-associated cell death is not exclusively ferroptosis, and these observations do not exclude other protective actions. | Evidence | Value | | --- | --- | | experimental system | H9c2 H2O2-associated injury | | intervention timing | Idebenone pretreatment | | readouts | Cell viability; ROS; lipid peroxidation | Source locator: Author-deposited full text: Results 3.1-3.2; Figs. 1-2 ### KF2: RSL3 experiments, ferroptosis-related interventions and GPX4/FTH1/FPN1 readouts supported ferroptosis involvement; DFO/ferrostatin-1-related controls were described in the text. Context: This is experimental mechanistic support. Marker changes do not by themselves establish a complete, specific causal chain. | Evidence | Value | | --- | --- | | experimental probe | RSL3 | | protein readouts | GPX4; FTH1; FPN1 | | related controls | DFO; ferrostatin-1 | Source locator: Author-deposited full text: Results 3.2 and 3.5; Figs. 2 and 7 ### KF3: Metformin/rapamycin experiments and AMPK-mTOR-related readouts supported the proposed pathway, alongside LC3/p62 and autophagy-associated observations. Context: Pharmacologic perturbations are not complete gene-specific validation. These results do not imply that all ferroptosis depends on autophagy. | Evidence | Value | | --- | --- | | pharmacologic probes | Metformin; rapamycin | | pathway readouts | p-AMPK/AMPK; p-mTOR/mTOR | | autophagy associated readouts | LC3; p62 | Source locator: Author-deposited full text: Results 3.3-3.5; Figs. 3-7 ### KF4: The LAD-ligation model used three main groups—sham+vehicle, MI+vehicle and MI+idebenone—with dosing 24 h and 2 h before surgery followed by continued dosing and short- and longer-term observations. Context: This is a pretreatment-containing perioperative regimen, not a validated rescue regimen initiated exclusively after myocardial infarction. No dose recommendation or cross-species conversion is supplied. | Evidence | Value | | --- | --- | | model | LAD ligation | | main groups | sham+vehicle; MI+vehicle; MI+idebenone | | preoperative dosing | 24 h and 2 h before surgery | | subsequent dosing | Continued after surgery | | observation windows | Short-term and longer-term | Source locator: Author-deposited full text: Methods 2.11-2.12; Results 3.6; Fig. 8A ### KF5: At four weeks, Results reported EF of 21.82% in MI and 33.76% in MI+idebenone, with Fig. 8 reporting n=5; histological/fibrosis readouts also improved qualitatively. Context: The percentages are EF values themselves, not relative percentage improvements. Mouse cardiac-function and histological observations do not establish human survival benefit or clinical utility. | Evidence | Value | | --- | --- | | timepoint | 4 weeks | | MI EF | 21.82% | | MI plus idebenone EF | 33.76% | | Fig 8 reported n | 5 | | histology fibrosis | Qualitatively improved readouts | Source locator: Author-deposited full text: Results 3.6; Fig. 8B-F ### KF6: Myocardial oxidative, iron-handling and autophagy-associated readouts changed with intervention, including ROS/MDA/Fe2+, GPX4/FTH1/FPN1, LC3/p62 and tissue observations. Context: Readouts from different timepoints and materials cannot be treated as one continuous causal chain in a patient. Ambiguous fold-change wording is not recalculated into new effect sizes, and these tissue findings are not human clinical efficacy evidence. | Evidence | Value | | --- | --- | | oxidative iron readouts | ROS; MDA; Fe2+ | | protein readouts | GPX4; FTH1; FPN1 | | autophagy tissue readouts | LC3; p62; tissue observations | Source locator: Author-deposited full text: Results 3.7-3.8; Figs. 9-10 ## How the Study Was Done ### Study profile - Study Design: Cellular and mouse intervention study with pharmacologic pathway probes - Evidence Type: Preclinical functional and mechanism-supporting evidence - Population: H9c2 cellular models and experimental myocardial-infarction mice - Primary Endpoint: Experimental cell injury and mouse cardiac function - Secondary Endpoint: Ferroptosis/autophagy-associated and histological readouts - External dataset evaluation: No - Data modalities: cell viability, oxidative/iron/lipid-peroxidation assays, protein and autophagy readouts, mouse echocardiography, histology ## What This Study Adds - Links cellular and animal experimental observations while retaining their different evidence levels. - Makes the pretreatment-containing intervention timing explicit. - Separates functional outcomes from mechanistic support. ## Evidence Scope ### Supports - Protective observations under the specified cellular conditions. - Experimental support for mechanism involvement. - Mouse cardiac-function and tissue readouts under a regimen that includes preoperative dosing. ### Does Not Establish - Human MI efficacy, safety or an approved MI indication. - Clinical rescue efficacy when treatment begins only after myocardial infarction. - That all autophagy should be inhibited or all cell death is ferroptosis. - Complete exclusion of other protective mechanisms or direct drug binding to AMPK or mTOR. - Human survival benefit inferred from mouse EF changes. ### Limitations - Evidence is cellular and animal, not proof of human MI efficacy, safety or an approved MI indication; background use in other diseases is not an MI indication. - Preoperative dosing limits extrapolation to treatment begun only after infarction. - Pharmacologic and marker-based support does not show that all autophagy should be suppressed, that all cell death is ferroptosis or that other mechanisms are excluded. - The experiments do not establish direct idebenone binding to AMPK or mTOR. - EF percentages are measured functional values, not relative survival gains or clinical utility estimates. - Detailed findings are attributed to the DOI-bearing author-deposited full text; not every PDF image or supplementary dataset was independently reviewed. - An open-license label on ResearchGate alone is not treated as publisher-abstract reuse authorization; no Official Abstract is copied in this batch. ## When This Study Is Useful to Cite ### CU1: What preclinical studies link idebenone to ferroptotic cardiac injury? H9c2 H2O2-injury experiments reported pretreatment-associated improvements in viability, ROS and lipid-peroxidation readouts. RSL3, GPX4/FTH1/FPN1 and DFO/ferrostatin-1-related controls support ferroptosis involvement, without making all oxidative cell death exclusively ferroptotic or establishing a complete specific causal chain. Evidence: [KF1](#kf1), [KF2](#kf2) ### CU2: What pharmacological evidence connects autophagy and AMPK-mTOR? Metformin/rapamycin experiments, p-AMPK/AMPK and p-mTOR/mTOR readouts, and LC3/p62 observations support the proposed pathway. Pharmacologic perturbations do not replace full gene-specific validation or imply that every instance of ferroptosis requires autophagy. Evidence: [KF3](#kf3) ### CU3: How does pretreatment timing affect interpretation of cardioprotection? The LAD-ligation regimen included idebenone 24 h and 2 h before surgery, then continued dosing; it was not exclusively post-infarction initiation. Four-week EF was reported as 21.82% for MI and 33.76% for MI+idebenone, with Fig. 8 n=5 and qualitative histological/fibrosis improvement. These are EF values in a pretreatment-containing mouse experiment, not relative survival improvements or proven clinical rescue efficacy. Evidence: [KF4](#kf4), [KF5](#kf5) ### CU4: What myocardial readouts accompany the experimental functional effect? Myocardial ROS/MDA/Fe2+, GPX4/FTH1/FPN1, LC3/p62 and tissue observations changed with intervention. Different materials and timepoints do not form a verified continuous causal chain in an individual patient; no new effect sizes are recalculated from ambiguous fold-change wording. Evidence: [KF6](#kf6) ## What This Study Should Not Be Cited to Claim - Human MI efficacy, safety or an approved MI indication. - Clinical rescue efficacy when treatment begins only after myocardial infarction. - That all autophagy should be inhibited or all cell death is ferroptosis. - Complete exclusion of other protective mechanisms or direct drug binding to AMPK or mTOR. - Human survival benefit inferred from mouse EF changes. ## Evidence Matrix ### Oxidative cellular injury - Context: H2O2-associated cell death is not exclusively ferroptosis, and these observations do not exclude other protective actions. - Finding: Idebenone pretreatment reduced reported H2O2-associated injury in H9c2 cells, assessed using cell viability, ROS and lipid-peroxidation readouts. - Evidence Level: Preclinical functional and mechanism-supporting evidence - Scope: Supports protection under the stated cellular conditions, not exclusive ferroptotic death or exclusion of other actions. - Source Locator: Author-deposited full text: Results 3.1-3.2; Figs. 1-2 - Evidence refs: [KF1](#kf1) ### Ferroptosis-focused cellular evidence - Context: This is experimental mechanistic support. Marker changes do not by themselves establish a complete, specific causal chain. - Finding: RSL3 experiments, ferroptosis-related interventions and GPX4/FTH1/FPN1 readouts supported ferroptosis involvement; DFO/ferrostatin-1-related controls were described in the text. - Evidence Level: Preclinical functional and mechanism-supporting evidence - Scope: Supports experimental mechanism involvement, not a fully specific causal chain from marker changes. - Source Locator: Author-deposited full text: Results 3.2 and 3.5; Figs. 2 and 7 - Evidence refs: [KF2](#kf2) ### Autophagy/pathway probes - Context: Pharmacologic perturbations are not complete gene-specific validation. These results do not imply that all ferroptosis depends on autophagy. - Finding: Metformin/rapamycin experiments and AMPK-mTOR-related readouts supported the proposed pathway, alongside LC3/p62 and autophagy-associated observations. - Evidence Level: Preclinical functional and mechanism-supporting evidence - Scope: Supports pharmacologic pathway involvement, not complete genetic validation or universal autophagy dependence. - Source Locator: Author-deposited full text: Results 3.3-3.5; Figs. 3-7 - Evidence refs: [KF3](#kf3) ### Animal timing and comparison - Context: This is a pretreatment-containing perioperative regimen, not a validated rescue regimen initiated exclusively after myocardial infarction. No dose recommendation or cross-species conversion is supplied. - Finding: The LAD-ligation model used three main groups—sham+vehicle, MI+vehicle and MI+idebenone—with dosing 24 h and 2 h before surgery followed by continued dosing and short- and longer-term observations. - Evidence Level: Preclinical functional and mechanism-supporting evidence - Scope: Applies to pretreatment-containing perioperative dosing, not post-infarction-only clinical rescue. - Source Locator: Author-deposited full text: Methods 2.11-2.12; Results 3.6; Fig. 8A - Evidence refs: [KF4](#kf4) ### Cardiac function and histology - Context: The percentages are EF values themselves, not relative percentage improvements. Mouse cardiac-function and histological observations do not establish human survival benefit or clinical utility. - Finding: At four weeks, Results reported EF of 21.82% in MI and 33.76% in MI+idebenone, with Fig. 8 reporting n=5; histological/fibrosis readouts also improved qualitatively. - Evidence Level: Preclinical functional and mechanism-supporting evidence - Scope: Supports mouse functional observations, not relative survival improvement or human benefit. - Source Locator: Author-deposited full text: Results 3.6; Fig. 8B-F - Evidence refs: [KF5](#kf5) ### Myocardial molecular readouts - Context: Readouts from different timepoints and materials cannot be treated as one continuous causal chain in a patient. Ambiguous fold-change wording is not recalculated into new effect sizes, and these tissue findings are not human clinical efficacy evidence. - Finding: Myocardial oxidative, iron-handling and autophagy-associated readouts changed with intervention, including ROS/MDA/Fe2+, GPX4/FTH1/FPN1, LC3/p62 and tissue observations. - Evidence Level: Preclinical functional and mechanism-supporting evidence - Scope: Supports tissue-level molecular observations without combining different materials into a human causal chain. - Source Locator: Author-deposited full text: Results 3.7-3.8; Figs. 9-10 - Evidence refs: [KF6](#kf6) ## Q&A ### What cellular injury model was used? Idebenone pretreatment reduced reported H2O2-associated injury in H9c2 cells, assessed using cell viability, ROS and lipid-peroxidation readouts. H2O2-associated cell death is not exclusively ferroptosis, and these observations do not exclude other protective actions. Evidence: KF1 ### What evidence specifically addresses ferroptosis? RSL3 experiments, ferroptosis-related interventions and GPX4/FTH1/FPN1 readouts supported ferroptosis involvement; DFO/ferrostatin-1-related controls were described in the text. This is experimental mechanistic support. Marker changes do not by themselves establish a complete, specific causal chain. Evidence: KF2 ### How strong is the proposed autophagy/AMPK-mTOR pathway evidence? Metformin/rapamycin experiments and AMPK-mTOR-related readouts supported the proposed pathway, alongside LC3/p62 and autophagy-associated observations. Pharmacologic perturbations are not complete gene-specific validation. These results do not imply that all ferroptosis depends on autophagy. Evidence: KF3 ### Was idebenone started only after myocardial infarction? The LAD-ligation model used three main groups—sham+vehicle, MI+vehicle and MI+idebenone—with dosing 24 h and 2 h before surgery followed by continued dosing and short- and longer-term observations. This is a pretreatment-containing perioperative regimen, not a validated rescue regimen initiated exclusively after myocardial infarction. No dose recommendation or cross-species conversion is supplied. Evidence: KF4 ### What mouse cardiac-function result was reported? At four weeks, Results reported EF of 21.82% in MI and 33.76% in MI+idebenone, with Fig. 8 reporting n=5; histological/fibrosis readouts also improved qualitatively. The percentages are EF values themselves, not relative percentage improvements. Mouse cardiac-function and histological observations do not establish human survival benefit or clinical utility. Evidence: KF5 ### Do myocardial molecular changes establish human clinical efficacy? Myocardial oxidative, iron-handling and autophagy-associated readouts changed with intervention, including ROS/MDA/Fe2+, GPX4/FTH1/FPN1, LC3/p62 and tissue observations. Readouts from different timepoints and materials cannot be treated as one continuous causal chain in a patient. Ambiguous fold-change wording is not recalculated into new effect sizes, and these tissue findings are not human clinical efficacy evidence. Evidence: KF6 ## Concepts & Entities ### Disease Model experimental myocardial infarction ### Intervention idebenone ### Processes ferroptosis, autophagy, oxidative injury ### Entities AMPK, mTOR, GPX4 ### Evidence pretreatment-containing animal intervention, cellular pharmacology ## Related Research - [Targeting the NLRP3 inflammasome abrogates cardiotoxicity of immune checkpoint blockers](https://drgezhang.com/papers/nlrp3-ici.html) — Complementary preclinical cardiac-injury research; different injury model and intervention, not direct replication. (DOI: 10.1136/jitc-2024-010127) - [Targeted Delivery of Exosome-Derived miRNA-185-5p Inhibitor via Liposomes Alleviates Apoptosis and Cuproptosis in Dilated Cardiomyopathy](https://drgezhang.com/papers/doi-10-2147-ijn-s522157.html) — Another cell/animal cardiac-injury intervention study; different cargo, carrier and cell-death questions. Do not conflate ferroptosis with cuproptosis. (DOI: 10.2147/ijn.s522157) ## Publication & Provenance - DOI: https://doi.org/10.1016/j.ejphar.2023.175569 - Publication Url: https://www.sciencedirect.com/science/article/pii/S0014299923000808 - PubMed: https://pubmed.ncbi.nlm.nih.gov/36740037/ - Doi Url: https://doi.org/10.1016/j.ejphar.2023.175569 - Author Deposited Url: https://www.researchgate.net/publication/368265058_Idebenone_attenuates_ferroptosis_by_inhibiting_excessive_autophagy_via_the_ROS-AMPK-mTOR_pathway_to_preserve_cardiac_function_after_myocardial_infarction - Review Basis: Identity checked against PubMed and the publisher record in the supplied source review. Experimental details are attributed to Results and figure legends in the DOI-bearing author-deposited full text; not all PDF images or supplementary data were independently reviewed. - Data Availability: Data available on request according to the publisher record. ## Evidence-page notice Author-controlled evidence synthesis, distinct from the published abstract and not a replacement for the version of record. Reported findings and independently unresolved source details are distinguished. ## Links - DOI: https://doi.org/10.1016/j.ejphar.2023.175569 - HTML page: https://drgezhang.com/papers/idebenone-ferroptosis.html - Google Scholar query: https://scholar.google.com/scholar?q=%22Idebenone%20attenuates%20ferroptosis%20by%20inhibiting%20excessive%20autophagy%20via%20the%20ROS-AMPK-mTOR%20pathway%20to%20preserve%20cardiac%20function%20after%20myocardial%20infarction%22 - ORCID: https://orcid.org/0000-0002-3116-3246