Shenfu injection: a review of pharmacological effects on cardiovascular diseases

Shenfu injection (SFI), composed of ginseng and aconite, is a Chinese patent developed from the classic traditional prescription Shenfu Decoction created more than 700 years ago. SFI has been widely used in China for over 30 years for treating cardiovascular diseases. The main components in it include ginsenosides and aconitum alkaloids. In recent years, the role of SFI in the treatment of cardiovascular diseases has attracted much attention. The pharmacological effects and therapeutic applications of SFI in cardiovascular diseases are summarized here, highlighting pharmacological features and potential mechanisms developments, confirming that SFI can play a role in multiple ways and is a promising drug for treating cardiovascular diseases.

Frontiers in Pharmacology frontiersin.org02 Xu et al. 10.3389/fphar.2024.1279584 2 SFI -basic characteristics and history of use SFI is a commonly used traditional Chinese medicine injection that has been used in clinical for over 30 years (Liu et al., 2021).It originated from the traditional Chinese classical formula "Shenfu Decoction", which was first recorded in Yan's Prescriptions for Rescuing Lives in the Song Dynasty (1253 AD).SFI is composed of Panax ginseng C.A.Mey [Araliaceae; Ginseng radix et rhizoma rubra] (RG) (Figure 2) and Aconitum carmichaelii Debx [Ranunculaceae; Aconiti lateralis radix praeparata] (RA) (Figure 3), which has the function of restoring Yang and invigorating Qi (Pei et al., 2021;Zhou et al., 2022).The existing studies reported that RG can be used to treat coronary heart disease and atherosclerosis by reducing blood lipid levels and improving inflammation (Hernández-García et al., 2019;Lu et al., 2019;Im, 2020).Additionally, it can inhibit arrhythmia by affecting the ion channels, such as activating potassium channel while blocking calcium channel and sodium current (Liu Z. et al., 2019;Gou et al., 2020).Furthermore, by ameliorating mitochondrial function and reducing oxidative damage in cardiomyocytes, it can prevent ventricular remodeling and heart failure.Moreover, it has the potential to improve the function of vascular endothelial cells, thereby lowering blood pressure (Yang F. et al., 2022;Liu et al., 2022).Meanwhile, RA has cardiotonic effects by accelerating βadrenergic receptor synthesis (Tong et al., 2021), has antiinflammatory effects through the Toll-like receptor4/Nuclear factor κB (TLR4/NF-κB) pathway (Yan et al., 2020), and has antiarrhythmic effects (Wang et al., 2023).SFI, composed of RA and RG, is a common drug for the treatment of CVDs.
Modern chemical studies have shown that SFI mainly contains ginsenosides, aconite alkaloids, organic acids, nucleosides, amino acids and other components (Song et al., 2015).Ginsenosides and aconite alkaloids are the main active components of SFI.The content of ginsenosides is 676-742 μg/mL, and the content of aconite alkaloids is 3-7 μg/mL (Yang et al., 2014;Ge et al., 2015;Song et al., 2015).It is known that aconite has certain toxicity, and the use of RG and RA in combination can achieve the effect of potentiation and detoxification.Ginsenosides can promote the metabolism of the toxic component aconitine, prolong the elimination half-life of active ingredients such as hypaconitine, benzoylmesaconine and songorine, and significantly increase the in vivo exposure of active ingredients.At the same time, some studies have found that ginseng can inhibit the ion disorders, toxicity in calcineurin-nuclear factor of activated T cells (CaN-NFAT3) pathway and inhibition of the cytochrome P450 2J3 (CYP2J3) expression caused by aconitine, and enhance the antioxidant effect of myocardial cells (Liu et al., 2020;Yang et al., 2021;Chen Z. Y. et al., 2022;Bao et al., 2023).Therefore, the compatibility of aconite and ginseng has the effect of 'reducing toxicity and increasing efficiency'.
Modern studies have shown that SFI is almost safe at conventional therapeutic doses, and the incidence of adverse reactions is relatively low  Structural formula of ginsenoside Rg1.

Pharmacological activities of SFI on CVDs
Many studies have confirmed that SFI has therapeutic effects on a variety of CVDs, such as myocardial hypertrophy, heart failure, ischemia-reperfusion injury, cardiac arrest, and arrhythmia.Its mechanism of action is mainly related to reducing inflammation Structural formula of ginsenoside Rg2.Structural formula of ginsenoside Rh2.

FIGURE 10
Structural formula of ginsenoside Rc.
Frontiers in Pharmacology frontiersin.orgthrough NF-κB signaling pathway, oxidative stress by reducing free radical damage, dilating blood vessels by increasing nitric oxide (NO) content, decreasing fibrosis through TGF-?/Smads signaling pathway and reducing apoptosis by increasing the expression of apoptosis proteins (Figure 13).

Cardiac hypertrophy and heart failure
Cardiac hypertrophy is mainly manifested as thickening of ventricular walls and an increase in cardiomyocyte size, closely related to cardiac fibrosis and heart failure (Feng et al., 2019).As time progresses and in settings of sustained stress, cardiac hypertrophy and fibrosis will eventually lead to heart failure (Gallo et al., 2019;Zhao D. et al., 2021;Methatham et al., 2021).Inhibiting cardiac hypertrophy and fibrosis is an effective way to treat heart failure.
TGF-?/Smads plays a key role in the pathogenesis of myocardial fibrosis.The previous research suggested that TGF-?1 bind to receptor, recruited and phosphorylated type I receptor, induced phosphorylation of Smad2 and Smad3.The phosphorylated Smad2 and Smad3 formed a trimer complex with Smad4.Then the complex transferred into the nucleus and regulated the transcription of target genes, regulating the synthesis of collagen fibers and the activation of fibroblasts.Smad7 can competitively bind to the type I receptor of TGF-?1 and inhibit the signal transduction of TGF-?1/ Smads pathway (Stewart et al., 2018;Wang L. et al., 2021).Ni et al. (2017) found that SFI can effectively improve cardiac function in the rate model of congestive heart failure (CHF) and attenuate ventricular remodeling and myocardial fibrosis by regulating TGF-?/Smads signaling pathway, upregulating Smad7 and downregulating TGF-? 1, Smad2 and Smad3 gene expression.
Inflammatory response is trigged in the myocardial infarction area which can result in cardiac remodeling and heart failure, accumulating high levels of monocytes and neutrophils (Halade and Lee, 2022).Inflammatory cells can also stimulate repair pathways, with increasing the content of extracellular matrix in the myocardium, including matrix metalloproteinase-9 (MMP-9) and collagen (Valiente-Alandi et al., 2018).SFI has antiinflammatory effect, which can reduce the content of inflammatory factors such as tumor necrosis factor-α (TNF-α), interleukin-1?(IL-1?) and interleukin-6 (IL-6) in serum of rats, and also reduce the expression of fibronectin, collagen I, collagen III and MMP-9 protein (Ni et al., 2017;Guo et al., 2022).
Endothelial function is essential for maintaining normal vasomotor function, and disruption of this function can result in vasomotor dysfunction (Sabe et al., 2022).When heart failure occurs, endothelial function is impaired, with vasoconstrictor substances increasing, and vasodilator substances decreasing (Monteiro et al., 2019).NO is the most famous vasodilator, while endothelin-1 (ET-1) is the most widely recognized vasoconstrictor (Miyauchi and Sakai, 2019).The production of NO mainly depends on the activity and quantity of endothelial nitric oxide synthase (eNOS).When the expression of eNOS mRNA increases, the number of eNOS synthesis increases.When eNOS binds with calmodulin (CaM), the activity of eNOS enchance, adversely, when binds with caveolin-1 (Cav-1), decrease.The phosphorylation of eNOS depends on the phosphatidylinositol 3-kinase/protein kinase B (PI3K-Akt) signaling pathway, which produces phosphorylated tyrosine residues, thereby provides an anchor site for the recruitment of PI3K to the membrane (Garcia and Sessa, 2019;Suvorava et al., 2022).Zhu et al. (2020) found that SFI can increase the expression of eNOS mRNA and CaM and promote NO synthesis, decrease the expression of Cav-1 and ET-1 content, promote eNOS phosphorylation via the PI3K/Akt signaling pathway.

Ischemia-reperfusion injury
Myocardial ischemia-reperfusion injury is a significant factor that has a negative impact on the prognosis of myocardial infarction patients, causing myocardial stunning, no-reflow phenomena, reperfusion arrhythmia, and even permanent cardiomyocyte death.Therefore, it is critical to understand the mechanism of myocardial ischemia reperfusion and develop efficient treatments (Mokhtari-Zaer et al., 2018;Deng, 2021).Structural formula of benzoylmesaconine.

FIGURE 12
Structural formula of aconitine.
Frontiers in Pharmacology frontiersin.org Apoptosis is involved in the pathogenesis of various CVDs and plays an important role in myocardial ischemia-reperfusion injury.Bcl-2 family proteins are important regulators of the process, prevent apoptosis by acting upstream of apoptosis proteins, such as caspase-3 and caspase-9 (King et al., 2023;Sahoo et al., 2023).Previous research found that SFI can upregulate the anti-apoptosis protein Bcl-2 and inhibit the consecutive activation of caspase-3 and caspase-9, both of which are intimately associated to apoptosis (Cao et al., 2005;Wang et al., 2009;Guo et al., 2016).
Oxidative stress is a risk factor for CVDs, and abnormally increased reactive oxygen species (ROS) is the main cause of oxidative stress.ROS combined with proteins and lipids damage cardiomyocytes (Peng et al., 2022).The superoxide dismutase (SOD) is the major antioxidant enzyme that degrade superoxide (Eleutherio et al., 2021).The glutathione system is widely recognized as one of the most potent endogenous antioxidant systems within cardiovascular system.Glutathione, one of the endogenous antioxidant molecules, can directly scavenge ROS caused by myocardial ischemia (Panday et al., 2020;Tan et al., 2023).Taurine is a common endogenous sulfurcontaining amino acid with antioxidant activity and can inhibit the abnormal increase of ROS (Li et al., 2020).SFI dramatically decreased glutathione and taurine, increased SOD activity, and inhibited the rise in malondialdehyde (MDA), which is closely related to oxidative stress (Zheng et al., 2004;Cao et al., 2005;Wu et al., 2019).
Numerous studies have revealed that NO is a vasodilator with the ability to operate on cardiomyocytes and vascular endothelium via a variety of signaling pathways (Boycott et al., 2020;Cyr et al., 2020).The action of eNOS is primarily responsible for NO generation.NO generated by eNOS phosphorylation induces soluble guanylate cyclase (sGC) to create cyclic guanosine monophosphate (cGMP), a second messenger with cardiovascular protective properties (Mount et al., 2007;Zhang Q. et al., 2020;Lee et al., 2021).SFI activated eNOS phosphorylation via Akt, thereby promoting the production of NO (Wu et al., 2011;Wang et al., 2018).

Cardiac arrest
Cardiac arrest (CA), one of the leading causes of death, has a significant impact on the public health, particularly due to its persistent increase worldwide (Vazquez and Sudhir, 2023).Post-cardiac arrest syndrome (PCAS) is a group of diseases characterized by systemic ischemia/reperfusion injury, hypoxic brain injury and myocardial dysfunction after cardiac arrest (Jou et al., 2020).It is associated with cardiovascular ischemia/reperfusion injury and cardiovascular toxicity, including factors such as excessive activation of inflammatory cytokines and catecholamines (Lazzarin et al., 2022).Matrix metalloproteinases, tumor necrosis factor, and interleukins each have a special prognostic function in PCAS.High inflammatory cytokine levels have been linked to poor neurologic and/or death outcomes (Jou et al., 2020).
NF-κB signaling pathway is one of the important pathways regulating inflammation and plays a key regulatory role in the occurrence and development of various CVDs (Cheng et al., 2023).Study have reported that in cardiac arrest swine, SFIremarkedly decreased levels of many inflammatory cytokines, such as TNF-α, IL-6, mRNA and protein levels of myocardial TLR4 and NF-κB (Gu et al., 2021).TLR4, as a 'portal' protein, regulates the initiation of the inflammatory chain reaction of the body's immunity and mediates the inflammatory response (Fitzgerald and Kagan, 2020).

Arrhythmia
The normal electrical activity of the heart is initiated by special pacemaker cells located in the sinoatrial node (Liang et al., 2021).Dysfunction or loss of pacemaker cells can cause arrhythmia (Liu and Yuan, 2021b).The transplantation of stem cells is regarded as a kind of feasible treatment for arrhythmia (Sattayaprasert et al., 2020).It has been reported that bone marrow mesenchymal stem cells (BMSCs) with specific phenotypes can be transformed into The pharmacological effect of Shenfu injection (SFI) on cardiovascular diseases.
In vitro, SFI can activate inward pacemaker current of BMSCs in a concentration-dependent manner, increase HCN4 expression and cAMP content in BMSCs, induce BMSCs proliferation, promote their differentiation into pacemaker-like cells (Zhao X. et al., 2021).The HCN4 gene serves as the molecular basis for the pacemaker current, contributing significantly to inward current during depolarization and playing a crucial role in the generation and autonomous regulation of heart rate (Bucchi et al., 2012;D'Souza et al., 2021;Hoekstra et al., 2021).Bone marrow mesenchymal stem cells treated with SFI retained the function of sinoatrial node in rabbits with sinoatrial node syndrome, improved the expression of HCN4 gene and gap junction proteins (Cx43 and Cx45), and significantly upregulated the expression of cAMP in sinoatrial node (Chen Q. et al., 2022).
In addition, SFI has certain pharmacological effects on nervous system, respiratory system and digestive system.For example, SFI has a protective effect on lipopolysaccharide-induced septic shock in rabbits (Liu X. et al., 2019).It can reduce bile duct injury in rats with acute obstructive cholangitis (Tan et al., 2019) and increase the level of acetylcholine in acute liver injury in septic young rats (Wu et al., 2022).It also has a protective effect on lung and intestinal epithelial injury in mice with acute gastrointestinal injury (Zheng et al., 2022).

Clinical trial of SFI in CVDs
There are many clinical trials related to SFI, and nine clinical trials have been conducted to study its role in the treatment of CVDs.These clinical trials have demonstrated that SFI can improve cardiac function and corresponding indicators in patients with CVDs, including heart failure, myocardial infarction, cardiac arrest after resuscitation, coronary syndrome, coronary heart disease and other diseases (Table 1).

The effect of SFI in patients with acute heart failure
Infusion of SFI in 80 patients with acute heart failure can improve cardiac function, clinical symptoms and quality of life (Wang et al., 2019b).Fifty patients with acute decompensated heart failure were treated with combination therapy.Compared with simple infusion of levosimendan, the improvement of hemodynamic parameters including CI, cardiac output and stroke volume index was more significant, especially in patients with acute decompensated heart failure with hypotension (Li M. et al., 2022).

5.2
The effect of SFI in patients with chronic heart failure SFI was used to treat 80 patients with acute exacerbation of chronic heart failure, which could improve the symptoms, quality of life, exercise tolerance, improve left ventricular ejective fraction (LVEF), reduce left ventricular end diastolic diameter (LVED), plasma brain natriuretic peptide (BNP) and cytokine Fas, TNF-α, IL-6 levels, reduce mortality and readmission rate (Liu et al., 2015).SFI was administered to 171 patients suffering from chronic heart failure on the basis of Western medicine.Compared with Western medicine alone, it could reduce the all-cause mortality by 30.99%, increase the 6-min walking distance (6MWT) and improve the quality of life (Wang X. et al., 2017).Patients with coronary heart disease complicated with chronic heart failure were treated with SFI and furosemide injection for 7 days.The effect was better than that of furosemide injection alone in improving cardiac function, LVEF, N-terminal B-type natriuretic peptide (NT-proBNP), TNF-α, IL-6 (Gao et al., 2021).For 7 days, SFI and sodium nitroprusside were administered intravenously to 91 patients who had coronary heart disease and chronic heart failure.The effect was better than that of sodium nitroprusside injection alone in improving cardiac function, LVEF, NT-proBNP and BNP (Guo et al., 2021).

The effect of SFI in patients with other CVDs
Infusion of SFI 1h before coronary angiography in 74 patients with coronary syndrome undergoing percutaneous coronary intervention (PCI) significantly reduced the level of neutrophil gelatinase-associated lipocalin (NGAL) in urine and effectively prevent contrast-induced acute kidney injury (Guo et al., 2017).SFI was used to treat patients with ST-segment elevation myocardial infarction before PCI and maintained for 5 days after PCI.Compared with patients treated with placebo, SFI reduced the area of myocardial infarction (Wang X. et al., 2021).A total of 492 cardiac arrest patients received bi-daily intravenous SFI infusions over a span of 28 days.The 28-day and 90-day survival rates were improved, the mechanical ventilation time and hospitalization time were shortened, and the recovery of spontaneous circulation after cardiac arrest was effectively improved (Zhang et al., 2017).

Concluding remarks and future perspectives
The results of numerous research studies in the past have demonstrated that SFI exerts varying degrees of therapeutic effects on various types of CVDs, such as heart failure, myocardial hypertrophy, myocardial ischemia, cardiac arrest, arrhythmia, and so forth.SFI plays a therapeutic role through multiple different targets, such as TGF-Smads, PI3K-Akt, eNOS-Akt pathway, and so on.SFI has been used in China for more than 30 years.It is a commonly used drug for clinical treatment of CVDs.No serious adverse reactions have been found so far.
In general, SFI is a promising drug for the treatment of CVDs.However, SFI has the characteristics of multi-component, multitarget and multi-pathway, which increases the difficulty of research.There is still a lack of in-depth study on the mechanism of SFI.In addition, large-scale, high-quality, multi-center clinical trials are needed to determine the comparison of SFI with traditional CVDs treatment regimens.

FIGURE 4
FIGURE 4Structural formula of ginsenoside Re.

FIGURE 8
FIGURE 8Structural formula of ginsenoside Rd.

TABLE 1
Clinical trial of SFI in cardiovascular disease.