Carnosic acid mitigates doxorubicin-induced cardiac toxicity: Evidence from animal and cell model investigations

Document Type : Original Article


1 Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran

2 Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran

3 Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran

4 Ghaem Hospital, Department of Pathology, Mashhad University of Medical Sciences, Mashhad, Iran


Objective(s): Utilization of doxorubicin (DOX) as a chemotherapy medication is limited due to its cardiotoxic effects. Carnosic acid exerts antioxidant, anti-inflammatory, besides cytoprotective effects. The objective of this study was to investigate the ability of carnosic acid to protect rat hearts and the MCF7 cell line against cardiotoxicity induced by DOX.
Materials and Methods: The study involved the classification of male Wistar rats into seven groups: 1) Control 2) DOX (2 mg/kg, every 48h, IP, 12d), 3-5) Carnosic acid (10, 20, 40 mg/kg/day, IP, 16d)+ DOX, 6) Vitamin E (200 mg/kg, every 48h, IP, 16d)+ DOX 7) Carnosic acid (40 mg/kg/day, IP, 16d). Finally, cardiac histopathological alterations, ECG factors, carotid blood pressure, left ventricular function, heart-to-body weight ratio, oxidative (MDA, GSH), inflammatory (IL-1β, TNF-α), plus apoptosis (caspase 3, 8, 9, Bcl-2, Bax) markers were evaluated. DOX toxicity and carnosic acid ameliorative effect were evaluated on MCF7 cells using the MTT assay.
Results: DOX augmented the QRS duration, QA, RRI, STI, and heart-to-body weight ratio, and reduced HR, LVDP, Min dP/dt, Max dP/dt, blood pressure, boosted MDA, TNF-α, IL1-β, caspase 3,8,9, Bax/Bcl-2 ratio, decreased GSH content, caused fibrosis, necrosis, and cytoplasmic vacuolization in cardiac tissue but carnosic acid administration reduced the toxic effects of DOX. The cytotoxic effects of DOX were not affected by carnosic acid at concentrations of 5 and 10 μM.
Conclusion: Carnosic acid as an anti-inflammatory and antioxidant substance is effective in reducing DOX-induced damage by enhancing antioxidant defense and modifying inflammatory signal pathway activity and can be used as an adjunct in treating DOX cardiotoxicity.


Main Subjects

1. Eisvand F, Imenshahidi M, Ghasemzadeh Rahbardar M, Tabatabaei Yazdi SA, Rameshrad M, Razavi BM, et al. Cardioprotective effects of alpha‐mangostin on doxorubicin‐induced cardiotoxicity in rats. Phytother Res 2022; 36:506-524.
2. Rahbardar MG, Eisvand F, Rameshrad M, Razavi BM, Hosseinzadeh H. In vivo and in vitro protective effects of rosmarinic acid against doxorubicin-induced cardiotoxicity. Nutr Cancer 2022; 74:747-760.
3. Schimmel KJ, Richel DJ, van den Brink RB, Guchelaar H-J. Cardiotoxicity of cytotoxic drugs. Cancer Treat Rev 2004; 30:181-191.
4. Deavall DG, Martin EA, Horner JM, Roberts R. Drug-induced oxidative stress and toxicity. J Toxicol 2012; 2012:645460.
5. Mantawy EM, El-Bakly WM, Esmat A, Badr AM, El-Demerdash E. Chrysin alleviates acute doxorubicin cardiotoxicity in rats via suppression of oxidative stress, inflammation and apoptosis. Eur J Pharmacol 2014; 728:107-118.
6. Doroshow JH, Locker GY, Myers C. Enzymatic defenses of the mouse heart against reactive oxygen metabolites: alterations produced by doxorubicin. J Clin Investig 1980; 65:128-135.
7. Razmaraii N, Babaei H, Nayebi AM, Asadnasab G, Helan JA, Azarmi Y. Cardioprotective effect of phenytoin on doxorubicin-induced cardiac toxicity in a rat model. J Cardiovasc Pharmacol 2016; 67:237-245.
8. Alavi MS, Fanoudi S, Ghasemzadeh Rahbardar M, Mehri S, Hosseinzadeh H. An updated review of protective effects of rosemary and its active constituents against natural and chemical toxicities. Phytother Res 2021; 35:1313-1328.
9. Rahbardar MG, Hosseinzadeh H. Therapeutic effects of rosemary (Rosmarinus officinalis L.) and its active constituents on nervous system disorders. Iran J Basic Med Sci 2020; 23:1100-1112.
10. Birtić S, Dussort P, Pierre F-X, Bily AC, Roller M. Carnosic acid. Phytochemistry 2015; 115:9-19.
11. Pearson DA, Frankel EN, Aeschbach R, German JB. Inhibition of endothelial cell-mediated oxidation of low-density lipoprotein by rosemary and plant phenolics. J Agric Food Chem 1997; 45:578-582.
12. Satoh T, Kosaka K, Itoh K, Kobayashi A, Yamamoto M, Shimojo Y, et al. Carnosic acid, a catechol‐type electrophilic compound, protects neurons both in vitro and in vivo through activation of the Keap1/Nrf2 pathway via S‐alkylation of targeted cysteines on Keap1. J Neurochem 2008; 104:1116-1131.
13. Mengoni ES, Vichera G, Rigano LA, Rodriguez-Puebla ML, Galliano SR, Cafferata EE, et al. Suppression of COX-2, IL-1β and TNF-α expression and leukocyte infiltration in inflamed skin by bioactive compounds from Rosmarinus officinalis L. Fitoterapia 2011; 82:414-421.
14. Oh J, Yu T, Choi SJ, Yang Y, Baek HS, An S, et al. Syk/Src pathway-targeted inhibition of skin inflammatory responses by carnosic acid. Mediators Inflamm 2012; 2012:781375.
15. Shan W, Gao L, Zeng W, Hu Y, Wang G, Li M, et al. Activation of the SIRT1/p66shc antiapoptosis pathway via carnosic acid-induced inhibition of miR-34a protects rats against nonalcoholic fatty liver disease. Cell Death Dis 2015; 6:e1833.
16.Nakisa N, Rahbardar MG. Action mechanisms of antirheumatic herbal medicines. In: Toumi H, editor. Rheumatoid Arthritis. 1st ed. IntechOpen; 2021.p. 1-16.
17. Nakisa N, Ghasemzadeh Rahbardar M. Therapeutic potential of rosemary (Rosmarinus officinalis L.) on sports injuries: a patent review. Res J pharmacogn 2022; 9:71-83.
18. Liu P, Dong J. Protective effects of carnosic acid against mitochondria‑mediated injury in H9c2 cardiomyocytes induced by hypoxia/reoxygenation. Exp Ther Med 2017; 14:5629-5634.
19. Sahu BD, Putcha UK, Kuncha M, Rachamalla SS, Sistla R. Carnosic acid promotes myocardial antioxidant response and prevents isoproterenol-induced myocardial oxidative stress and apoptosis in mice. Mol Cell Biochem 2014; 394:163-176.
20. Ghasemzadeh Rahbardar M, Hemadeh B, Razavi BM, Eisvand F, Hosseinzadeh H. Effect of carnosic acid on acrylamide induced neurotoxicity: in vivo and in vitro experiments. Drug Chem Toxicol 2020; 45:1528-1535.
21. Wang QL, Li H, Li XX, Cui CY, Wang R, Yu NX, et al. Acute and 30-day oral toxicity studies of administered carnosic acid. Food Chem Toxicol 2012; 50:4348-4355.
22. Razmaraii N, Babaei H, Nayebi AM, Assadnassab G, Helan JA, Azarmi Y. Cardioprotective effect of grape seed extract on chronic doxorubicin-induced cardiac toxicity in Wistar rats. Adv Pharm Bull 2016; 6:423-433.
23. Razavi BM, Hosseinzadeh H, Movassaghi AR, Imenshahidi M, Abnous K. Protective effect of crocin on diazinon induced cardiotoxicity in rats in subchronic exposure. Chem Biol Interact 2013; 203:547-555.
24. Uchiyama M, Mihara M. Determination of malonaldehyde precursor in tissues by thiobarbituric acid test. Anal Biochem 1978; 86:271-278.
25. Ghasemzadeh Rahbardar M, Cheraghi Farmed H, Hosseinzadeh H, Mehri S. Protective effects of selenium on acrylamide-induced neurotoxicity and hepatotoxicity in rats. Iran J Basic Med Sci 2021; 24:1041-1049.
26. Ghasemzadeh Rahbardar M, Razavi BM, Hosseinzadeh H. Investigating the ameliorative effect of alpha‐mangostin on development and existing pain in a rat model of neuropathic pain. Phytother Res 2020; 34:3211-3225.
27. Moron MS, Depierre JW, Mannervik B. Levels of glutathione, glutathione reductase and glutathione S-transferase activities in rat lung and liver. Biochim Biophys Acta Gen Subj 1979; 582:67-78.
28. Mohammadzadeh L, Rahbardar MG, Razavi BM, Hosseinzadeh H. Crocin Protects Malathion-induced Parkinson-like Disease by Inhibiting Apoptosis and α-synuclein Accumulation in Rats’ Striatum. J Mol Neurosci 2022; 72:983-993.
29. Rahman AM, Yusuf SW, Ewer MS. Anthracycline-induced cardiotoxicity and the cardiac-sparing effect of liposomal formulation. Int J Nanomedicine 2007; 2:567-583.
30. Hequet O, Le Q, Moullet I, Pauli E, Salles G, Espinouse D, et al. Subclinical late cardiomyopathy after doxorubicin therapy for lymphoma in adults. J Clin Oncol 2004; 22:1864-1871.
31. Boghdady NAE. Antioxidant and antiapoptotic effects of proanthocyanidin and ginkgo biloba extract against doxorubicin‐induced cardiac injury in rats. Cell Biochem Funct 2013; 31:344-351.
32. Wortman JE, Lucas Jr VS, Schuster E, Thiele D, Logue GL. Sudden death during doxorubicin administration. Cancer 1979; 44:1588-1591.
33. Colak M, Parlakpinar H, Tasdemir S, Samdanci E, Kose E, Polat A, et al. Therapeutic effects of ivabradine on hemodynamic parameters and cardiotoxicity induced by doxorubicin treatment in rat. Hum Exp Toxicol 2012; 31:945-954.
34. Ponikowski P, Anker SD, Chua TP, Szelemej R, Piepoli M, Adamopoulos S, et al. Depressed heart rate variability as an independent predictor of death in chronic congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol 1997; 79:1645-1650.
35. Tong J, Ganguly P, Singal P. Myocardial adrenergic changes at two stages of heart failure due to adriamycin treatment in rats. Am J Physiol 1991; 260:H909-H916.
36. van Acker SA, Kramer K, Voest EE, Grimbergen JA, Zhang J, van der Vijgh WJ, et al. Doxorubicin-induced cardiotoxicity monitored by ECG in freely moving mice A new model to test potential protectors. Cancer Chemother Pharmacol 1996; 38:95-101.
37. Ning R, Deng X, Wang Q, Ge Y. Carnosic acid protects against myocardial infarction by controlling oxidative stress and inflammation in rats. Rev bras farmacogn 2021; 31:794-804.
38. Hu S, Liu B, Yang M, Mao S, Ju H, Liu Z, et al. Carnosic acid protects against doxorubicin-induced cardiotoxicity through enhancing the Nrf2/HO-1 pathway. Food  Funct 2023; 14:3849-3862.
39. Aries A, Paradis P, Lefebvre C, Schwartz RJ, Nemer M. Essential role of GATA-4 in cell survival and drug-induced cardiotoxicity. Proc Natl Acad Sci USA 2004; 101:6975-6980.
40. Mokni M, Hamlaoui-Guesmi S, Amri M, Marzouki L, Limam F, Aouani E. Grape seed and skin extract protects against acute chemotherapy toxicity induced by doxorubicin in rat heart. Cardiovasc Toxicol 2012; 12:158-165.
41. Rashikh A, Pillai KK, Ahmad SJ, Akhtar M, Najmi AK. Aliskiren alleviates doxorubicin-induced nephrotoxicity by inhibiting oxidative stress and podocyte injury. J Renin Angiotensin Ald 2013; 14:14-22.
42. Swamy AV, Wangikar U, Koti B, Thippeswamy A, Ronad P, Manjula D. Cardioprotective effect of ascorbic acid on doxorubicin-induced myocardial toxicity in rats. Indian J Pharmacol 2011; 43:507-511.
43. Cheah HY, Šarenac O, Arroyo JJ, Vasić M, Lozić M, Glumac S, et al. Hemodynamic effects of HPMA copolymer based doxorubicin conjugate: a randomized controlled and comparative spectral study in conscious rats. Nanotoxicology 2017; 11:210-222.
44. Zhang Q-L, Yang J-J, Zhang H-S. Carvedilol (CAR) combined with carnosic acid (CAA) attenuates doxorubicin-induced cardiotoxicity by suppressing excessive oxidative stress, inflammation, apoptosis and autophagy. Biomed Pharmacother 2019; 109:71-83.
45. Manna P, Dewanjee S, Joardar S, Chakraborty P, Bhattacharya H, Bhanja S, et al. Carnosic acid attenuates doxorubicin-induced cardiotoxicity by decreasing oxidative stress and its concomitant pathological consequences. Food Chem Toxicol 2022; 166:113205.
46. Chatterjee K, Zhang J, Honbo N, Karliner JS. Doxorubicin cardiomyopathy. Cardiology 2010; 115:155-162.
47. Sadek KM, Mahmoud SFE, Zeweil MF, Abouzed TK. Proanthocyanidin alleviates doxorubicin-induced cardiac injury by inhibiting NF-kB pathway and modulating oxidative stress, cell cycle, and fibrogenesis. J Biochem Mol Toxicol 2021; 35:e22716.
48. Ibrahim MA, Ashour OM, Ibrahim YF, El-Bitar HI, Gomaa W, Abdel-Rahim SR. Angiotensin-converting enzyme inhibition and angiotensin AT1-receptor antagonism equally improve doxorubicin-induced cardiotoxicity and nephrotoxicity. Pharmacol Res 2009; 60:373-381.
49. Guo Q, Shen Z, Yu H, Lu G, Yu Y, Liu X, et al. Carnosic acid protects against acetaminophen-induced hepatotoxicity by potentiating Nrf2-mediated antioxidant capacity in mice. Korean J Physiol Pharmacol 2016; 20:15-23.
50. Wang Z-Q, Chen M-T, Zhang R, Zhang Y, Li W, Li Y-G. Docosahexaenoic acid attenuates doxorubicin-induced cytotoxicity and inflammation by suppressing NF-κB/iNOS/NO signaling pathway activation in H9C2 cardiac cells. J Cardiovasc Pharmacol 2016; 67:283-289.
51. Xiao Q, Qu Z, Zhao Y, Yang L, Gao P. Orientin ameliorates lps-induced inflammatory responses through the inhibitory of the nf-κb pathway and nlrp3 inflammasome. Evid Based Complement Alternat Med 2017; 2017:1-8.
52. Li Q, Liu L, Sun H, Cao K. Carnosic acid protects against lipopolysaccharide‑induced acute lung injury in mice. Exp Ther Med 2019; 18:3707-3714.
53. Kotamraju S, Konorev EA, Joseph J, Kalyanaraman B. Doxorubicin-induced apoptosis in endothelial cells and cardiomyocytes is ameliorated by nitrone spin traps and ebselen role of reactive oxygen and nitrogen species. J Biol Chem 2000; 275:33585-33592.
54. Czabotar PE, Lessene G, Strasser A, Adams JM. Control of apoptosis by the BCL-2 protein family: implications for physiology and therapy. Nat Rev Mol Cell Biol 2014; 15:49-63.
55. Smith CC, Guévremont D, Williams JM, Napper RM. Apoptotic cell death and temporal expression of apoptotic proteins Bcl‐2 and Bax in the hippocampus, following binge ethanol in the neonatal rat model. Alcohol Clin Exp Res 2015; 39:36-44.
56. Hosseinzadeh L, Behravan J, Mosaffa F, Bahrami G, Bahrami A, Karimi G. Curcumin potentiates doxorubicin-induced apoptosis in H9c2 cardiac muscle cells through generation of reactive oxygen species. Food Chem Toxicol 2011; 49:1102-1109.
57. Teng L, Fan L, Peng Y, He X, Chen H, Duan H, et al. Carnosic acid mitigates early brain injury after subarachnoid hemorrhage: possible involvement of the SIRT1/p66shc signaling pathway. Front Neurosci 2019; 13:26.
58. Chae CU, Albert CM, Moorthy M, Lee I-M, Buring JE. Vitamin E supplementation and the risk of heart failure in women. Circ Heart Fail 2012; 5:176-182.
59. Wang X, Teng Z, Wang H, Wang C, Liu Y, Tang Y, et al. Increasing the cytotoxicity of doxorubicin in breast cancer MCF-7 cells with multidrug resistance using a mesoporous silica nanoparticle drug delivery system. Int J Clin Exp Pathol 2014; 7:1337-1347.