THE EFFECT OF CARDİAC REHABİLİTATİON ON FERROPTOSİS İN PATİENTS WİTH CORONARY ARTERY DİSEASE

EVALUATİON OF FERROPTOSİS-RELATED BİOMARKERS İN INDİVİDUALS WİTH CORONARY ARTERY DİSEASE: THE IMPACT OF CARDİAC REHABİLİTATİON

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.

Study Overview

• Status: Recruiting
• Conditions: Coronary Artery Disease (CAD); Ferroptosis; Cardiac Rehab
• Intervention / Treatment: Behavioral: 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.

• Study Type: Interventional
• Enrollment (Estimated): 90
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Kayseri
    • Kayseri, Kayseri, Turkey (Türkiye), 38039
      • Recruiting
      • Erciyes University Faculty of Medicine
      • Contact: MUSTAFA Çalış, MD, Professor, MD, Professor; Phone Number: 22277 +90 352 207 6666; Email: mcalis@erciyes.edu.tr

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

• 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.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Cardiac Rehabilitation Group; Patients with coronary artery disease who will participate in a supervised cardiac rehabilitation program in addition to standard medical therapy. Peripheral venous blood samples will be collected before the initiation and after completion of the cardiac rehabilitation program for the assessment of ferroptosis-related gene expression and serum biomarkers.	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.
No Intervention: CAD Patients Declining Cardiac Rehabilitation; Patients with coronary artery disease who voluntarily decline participation in the cardiac rehabilitation program and continue to receive standard medical therapy. A single peripheral venous blood sample will be collected for the assessment of ferroptosis-related gene expression and serum biomarkers.
No Intervention: Healthy Control Group; Age- and sex-matched healthy volunteers without known cardiovascular or chronic diseases. A single peripheral venous blood sample will be collected for the assessment of ferroptosis-related gene expression and serum biomarkers.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in GPX4 Gene Expression	elative GPX4 gene expression in peripheral blood will be quantified using real-time quantitative polymerase chain reaction (RT-qPCR). Changes in GPX4 gene expression before and after completion of the cardiac rehabilitation program will be evaluated in patients undergoing cardiac rehabilitation. Baseline GPX4 gene expression levels will also be compared among patients undergoing cardiac rehabilitation, patients who decline participation in cardiac rehabilitation, and healthy control participants.	Baseline and immediately after completion of the cardiac rehabilitation program (8 weeks).

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in SLC7A11 Gene Expression	Relative SLC7A11 gene expression will be measured using RT-qPCR. Expression levels will be compared among the three study groups, and changes before and after cardiac rehabilitation will be evaluated in the rehabilitation group.	Baseline and immediately after completion of the cardiac rehabilitation program (8 weeks
Change in ACSL4 Gene Expression	Relative ACSL4 gene expression will be measured using RT-qPCR. Expression levels will be compared among the three study groups, and changes before and after cardiac rehabilitation will be evaluated in the rehabilitation group.	Baseline and immediately after completion of the cardiac rehabilitation program (8 weeks).
Change in FSP1 Gene Expression	Relative FSP1 gene expression will be measured using RT-qPCR. Expression levels will be compared among the three study groups, and changes before and after cardiac rehabilitation will be evaluated in the rehabilitation group.	Baseline and immediately after completion of the cardiac rehabilitation program (8 weeks).
Change in NRF2 Gene Expression	Relative NRF2 gene expression will be measured using RT-qPCR. Expression levels will be compared among the three study groups, and changes before and after cardiac rehabilitation will be evaluated in the rehabilitation group.	Baseline and immediately after completion of the cardiac rehabilitation program (8 weeks).
Change in TFRC Gene Expression	Relative TFRC gene expression will be measured using RT-qPCR. Expression levels will be compared among the three study groups, and changes before and after cardiac rehabilitation will be evaluated in the rehabilitation group.	Baseline and immediately after completion of the cardiac rehabilitation program (8 weeks).
Change in NCOA4 Gene Expression	Relative NCOA4 gene expression will be measured using RT-qPCR. Expression levels will be compared among the three study groups, and changes before and after cardiac rehabilitation will be evaluated in the rehabilitation group.	Baseline and immediately after completion of the cardiac rehabilitation program (8 weeks).
Change in Serum Free Iron Concentration	Serum free iron concentration will be measured using a validated laboratory assay. Levels will be compared among the three study groups, and changes before and after cardiac rehabilitation will be evaluated in the rehabilitation group.	Baseline and immediately after completion of the cardiac rehabilitation program (8 weeks).
Change in Serum 4-Hydroxynonenal (4-HNE) Concentration	Serum 4-hydroxynonenal concentration will be measured using an enzyme-linked immunosorbent assay (ELISA). Levels will be compared among the three study groups, and changes before and after cardiac rehabilitation will be evaluated in the rehabilitation group.	Baseline and immediately after completion of the cardiac rehabilitation program (8 weeks).
Change in Peak Oxygen Uptake (Peak VO₂)	Peak oxygen uptake (Peak VO₂) will be assessed using a symptom-limited cardiopulmonary exercise test (CPET). Changes in Peak VO₂ before and after completion of the cardiac rehabilitation program will be evaluated in patients undergoing cardiac rehabilitation. Baseline Peak VO₂ values will also be compared between patients undergoing cardiac rehabilitation and patients who decline participation in cardiac rehabilitation.	Baseline and immediately after completion of the cardiac rehabilitation program (8 weeks).

Collaborators and Investigators

• Sponsor: TC Erciyes University

Publications and helpful links

General Publications

• O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jan 29;61(4):e78-e140. doi: 10.1016/j.jacc.2012.11.019. Epub 2012 Dec 17. No abstract available.
• 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.
• 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 Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2010 Feb;17(1):1-17. doi: 10.1097/HJR.0b013e3283313592.
• 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.
• 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.
• 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. doi: 10.12932/AP-190125-2018. Online ahead of print.
• 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.
• 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.
• 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.
• Zhou Y, Zhou H, Hua L, Hou C, Jia Q, Chen J, Zhang S, Wang Y, He S, Jia E. Verification of ferroptosis and pyroptosis and identification of PTGS2 as the hub gene in human coronary artery atherosclerosis. Free Radic Biol Med. 2021 Aug 1;171:55-68. doi: 10.1016/j.freeradbiomed.2021.05.009. Epub 2021 May 8.
• Wang Y, Wu J. Ferroptosis: a new strategy for cardiovascular disease. Front Cardiovasc Med. 2023 Sep 4;10:1241282. doi: 10.3389/fcvm.2023.1241282. eCollection 2023.

Study record dates

Study Major Dates

• Study Start (Actual): January 1, 2026
• Primary Completion (Estimated): November 15, 2026
• Study Completion (Estimated): November 15, 2026

Study Registration Dates

• First Submitted: July 19, 2026
• First Submitted That Met QC Criteria: July 19, 2026
• First Posted (Actual): July 23, 2026

Study Record Updates

• Last Update Posted (Actual): July 23, 2026
• Last Update Submitted That Met QC Criteria: July 19, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Keywords: Coronary artery disease; cardiac rehabilitation; ferroptosis
• Additional Relevant MeSH Terms: Vascular Diseases; Cardiovascular Diseases; Heart Diseases; Arteriosclerosis; Arterial Occlusive Diseases; Coronary Disease; Myocardial Ischemia; Coronary Artery Disease; Therapeutics; Patient Care; Health Services; Health Care Facilities Workforce and Services; Rehabilitation; Aftercare; Continuity of Patient Care; Cardiac Rehabilitation
• Other Study ID Numbers: 2025/489; TTU-2025-15709 (Other Grant/Funding Number: Erciyes University Scientific Research Projects Unit)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: It is not planned to make individual participant data from this study publicly available.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No