Significance of the PI3K/AKT pathway in coronary microvascular dysfunction and advances in natural compound therapeutic research
Introduction: Coronary microvascular dysfunction (CMD) contributes to myocardial ischemia and adverse cardiovascular outcomes, but effective treatments remain limited.
Objective: This review aims to clarify the role of the phosphoinositide 3-kinase/protein kinase B (PI3K/AKT) pathway in CMD and assess the therapeutic potential of natural compounds that modulate it.
Methods: Available mechanistic and preclinical evidence on PI3K/AKT-mediated regulation of endothelial dysfunction, oxidative stress, inflammation, apoptosis, angiogenic repair, and microvascular homeostasis in CMD was reviewed. Natural compounds were classified into flavonoids, saponins, phenolic compounds, alkaloids, and polysaccharides, and their reported effects on PI3K/AKT-related downstream signaling axes were summarized.
Results: The PI3K/AKT pathway acts as a context-dependent signaling hub in CMD. Appropriate activation supports endothelial survival, vasodilation, antioxidant defense, anti-inflammatory responses, and inhibition of cardiomyocyte apoptosis through signaling axes including AKT/eNOS, AKT/NRF2, AKT/mTOR, and BCL-2/BAX/caspase. Preclinical studies indicate that several natural compounds can ameliorate cardiovascular injury by modulating these axes, thereby reducing oxidative stress and inflammation, limiting apoptosis and autophagy-related injury, and promoting angiogenesis and microvascular repair. However, most evidence derives from non-CMD-specific cellular and animal models and relies primarily on changes in pathway phosphorylation or pharmacological inhibitor experiments. Direct genetic validation, pharmacokinetic characterization, formulation standardization, and clinical evidence remain insufficient.
Conclusion: Natural compounds represent promising multi-target modulators of PI3K/AKT-related signaling in CMD, but their efficacy and pathway dependence require rigorous validation. Future studies should employ CMD-relevant models, objective microvascular endpoints, genetic approaches, optimized delivery systems, and integrative platforms such as organoids, multi-omics, artificial intelligence, and network pharmacology to facilitate clinical translation.
- Bradley C, Berry C. Definition and epidemiology of coronary microvascular disease. J Nucl Cardiol. 2022;29(4):1763-1775. doi: 10.1007/s12350-022-02974-x
- Sinha A, Rahman H, Perera D. Coronary microvascular disease: current concepts of pathophysiology, diagnosis and management. Cardiovasc Endocrinol Metab. 2021;10(1):22-30. doi: 10.1097/XCE.0000000000000223
- Yang Z, Lin S, Liu Y, et al. Traditional Chinese medicine in coronary microvascular disease. Front Pharmacol. 2022;13:929159. doi: 10.3389/fphar.2022.929159
- Naderi S. Microvascular coronary dysfunction: an overview. Curr Atheroscler Rep. 2018;20(2):7. doi: 10.1007/s11883-018-0710-5
- Li Y, Xia J, Jiang N, et al. Corin protects H2O2-induced apoptosis through PI3K/AKT and NF-κB pathway in cardiomyocytes. Biomed Pharmacother. 2018;97:594-599. doi: 10.1016/j.biopha.2017.10.090
- Wang L, Ge C, Zhang X. Sufentanil ameliorates oxygen-glucose deprivation/reoxygenation-induced endothelial barrier dysfunction in HCMECs via the PI3K/Akt signaling pathway. Exp Ther Med. 2022;24(1):437. doi: 10.3892/etm.2022.1136
- Xie W, Chen S, Wang W, Qin X, Kong C, Wang D. Nuciferine reduces vascular leakage and improves cardiac function in acute myocardial infarction by regulating the PI3K/AKT pathway. Sci Rep. 2024;14(1):7086. doi: 10.1038/s41598-024-57595-w
- Zhang T, Li L, Mo X, et al. Matairesinol blunts adverse cardiac remodeling and heart failure induced by pressure overload by regulating Prdx1 and PI3K/AKT/FOXO1 signaling. Phytomedicine. 2024;135:156054. doi: 10.1016/j.phymed.2024.156054
- Yin Y, Zhang Q, Zhao Q, et al. Tongxinluo attenuates myocardiac fibrosis after acute myocardial infarction in rats via inhibition of endothelial-to-mesenchymal transition. Biomed Res Int. 2019;2019:6595437. doi: 10.1155/2019/6595437
- Chen R, Chen T, Wang T, et al. Tongmai Yangxin pill reduces myocardial no-reflow by regulating apoptosis and activating PI3K/Akt/eNOS pathway. J Ethnopharmacol. 2020;261:113069. doi: 10.1016/j.jep.2020.113069
- Manning BD, Toker A. AKT/PKB signaling: navigating the network. Cell. 2017;169(3):381-405. doi: 10.1016/j.cell.2017.04.001
- Wang M, Zhang J, Gong N. Role of the PI3K/Akt signaling pathway in liver ischemia reperfusion injury: a narrative review. Ann Palliat Med. 2022;11(2):806-817. doi: 10.21037/apm-21-3286
- Yan LX, Liu YH, Xiang JW, et al. PIK3R1 targeting by miR-21 suppresses tumor cell migration and invasion by reducing PI3K/AKT signaling and reversing EMT, and predicts clinical outcome of breast cancer. Int J Oncol. 2016;48(2):471-484. doi: 10.3892/ijo.2015.3287
- He X, Li Y, Deng B, et al. The PI3K/AKT signalling pathway in inflammation, cell death and glial scar formation after traumatic spinal cord injury: mechanisms and therapeutic opportunities. Cell Prolif. 2022;55(9):e13275. doi: 10.1111/cpr.13275
- Mueller H, Stadtmann A, Van Aken H, et al. Tyrosine kinase Btk regulates E-selectin-mediated integrin activation and neutrophil recruitment by controlling phospholipase Cγ2 and PI3Kγ pathways. Blood. 2010;115(15):3118-3127. doi: 10.1182/blood-2009-11-254185
- Jin T, Zhang Y, Botchway BOA, et al. Curcumin can improve Parkinson’s disease via activating BDNF/PI3K/Akt signaling pathways. Food Chem Toxicol. 2022;164:113091. doi: 10.1016/j.fct.2022.113091
- Zheng J, Fan R, Wu H, et al. Directed self-assembly of herbal small molecules into sustained release hydrogels for treating neural inflammation. Nat Commun. 2019;10(1):1604. doi: 10.1038/s41467-019-09601-3
- Li Q, Li Z, Luo T, Shi H. Targeting the PI3K/AKT/mTOR and RAF/MEK/ERK pathways for cancer therapy. Mol Biomed. 2022;3(1):47. doi: 10.1186/s43556-022-00110-2
- King D, Yeomanson D, Bryant HE. PI3King the lock. J Pediatr Hematol Oncol. 2015;37(4):245-251. doi: 10.1097/MPH.0000000000000329
- Man HY, Wang Q, Lu WY, et al. Activation of PI3-kinase is required for AMPA receptor insertion during LTP of mEPSCs in cultured hippocampal neurons. Neuron. 2003;38(4):611-624. doi: 10.1016/S0896-6273(03)00228-9
- Wei L, Gou X, Su B, et al. Mahuang decoction attenuates airway inflammation and remodeling in asthma via suppression of the SP1/FGFR3/PI3K/AKT axis. Drug Des Devel Ther. 2022;16:2833-2850. doi: 10.2147/DDDT.S351264
- Liu X, Zhang W, Xu Y, et al. Targeting PI3Kγ/AKT pathway remodels LC3-associated phagocytosis-induced immunosuppression after radiofrequency ablation. Adv Sci (Weinh). 2022;9(7):e2102182. doi: 10.1002/advs.202102182
- Zhang J, Liu XH, Li C, et al. SNCG promotes the progression and metastasis of high-grade serous ovarian cancer via targeting the PI3K/AKT signaling pathway. J Exp Clin Cancer Res. 2020;39(1):79. doi: 10.1186/s13046-020-01589-9
- Zhu HH, Wang XT, Sun YH, et al. MicroRNA-486-5p targeting PTEN protects against coronary microembolization-induced cardiomyocyte apoptosis in rats by activating the PI3K/AKT pathway. Eur J Pharmacol. 2019;855:244-251. doi: 10.1016/j.ejphar.2019.03.045
- Pirat B, Bozbas H, Simsek V, et al. Impaired coronary flow reserve in patients with metabolic syndrome. Atherosclerosis. 2008;201(1):112-116. doi: 10.1016/j.atherosclerosis.2008.02.016
- Chen K, Li Y, Zhang X, Ullah R, Tong J, Shen Y. The role of the PI3K/AKT signalling pathway in the corneal epithelium: recent updates. Cell Death Dis. 2022;13(5):513. doi: 10.1038/s41419-022-04963-x
- Masi S, Rizzoni D, Taddei S, et al. Assessment and pathophysiology of microvascular disease: recent progress and clinical implications. Eur Heart J. 2021;42(26):2590-2604. doi: 10.1093/eurheartj/ehaa857
- Shaw RL, Norton CE, Segal SS. Apoptosis in resistance arteries induced by hydrogen peroxide: greater resilience of endothelium versus smooth muscle. Am J Physiol Heart Circ Physiol. 2021;320(4):H1625-H1633. doi: 10.1152/ajpheart.00956.2020
- Gao S, Zhang P, Zhang C, Bao F, Li H, Chen L. Meroterpenoids from Ganoderma sinense protect hepatocytes and cardiomyocytes from oxidative stress-induced injuries. Fitoterapia. 2018;131:73-79. doi: 10.1016/j.fitote.2018.10.009
- Jaeschke H, Mitchell JR. Use of isolated perfused organs in hypoxia and ischemia/reperfusion oxidant stress. Methods Enzymol. 1990;186:752-759. doi: 10.1016/0076-6879(90)86175-U
- Qin CC, Liu YN, Hu Y, Yang Y, Chen Z. Macrophage inflammatory protein-2 as mediator of inflammation in acute liver injury. World J Gastroenterol. 2017;23(17):3043-3052. doi: 10.3748/wjg.v23.i17.3043
- El-Benna J, Dang PM, Gougerot-Pocidalo MA, Elbim C. Phagocyte NADPH oxidase: a multicomponent enzyme essential for host defenses. Arch Immunol Ther Exp (Warsz). 2005;53(3):199-206.
- Xiao Q, Ye Q, Wang W, et al. Mild hypothermia pretreatment protects against liver ischemia reperfusion injury via the PI3K/AKT/FOXO3a pathway. Mol Med Rep. 2017;16(5):7520-7526. doi: 10.3892/mmr.2017.7501
- Wang M, Zhang J, Zhang J, et al. Methyl eugenol attenuates liver ischemia reperfusion injury via activating PI3K/Akt signaling. Int Immunopharmacol. 2021;99:108023. doi: 10.1016/j.intimp.2021.108023
- Tait SWG, Green DR. Mitochondria and cell death: outer membrane permeabilization and beyond. Nat Rev Mol Cell Biol. 2010;11(9):621-632. doi: 10.1038/nrm2952
- Christgen S, Tweedell RE, Kanneganti TD. Programming inflammatory cell death for therapy. Pharmacol Ther. 2022;232:108010. doi: 10.1016/j.pharmthera.2021.108010
- Han YH, Wang Y, Lee SJ, Jin MH, Sun HN, Kwon T. Regulation of anoikis by extrinsic death receptor pathways. Cell Commun Signal. 2023;21(1):227. doi: 10.1186/s12964-023-01247-5
- Wang Z, Macakova M, Bugai A, et al. P-TEFb promotes cell survival upon p53 activation by suppressing intrinsic apoptosis pathway. Nucleic Acids Res. 2023;51(4):1687-1706. doi: 10.1093/nar/gkad001
- Ai F, Chen M, Yu B, et al. Puerarin accelerate cardiac angiogenesis and improves cardiac function of myocardial infarction by upregulating VEGFA, Ang-1 and Ang-2 in rats. Int J Clin Exp Med. 2015;8(11):20821-20828.
- Li X, Sun S, Chen D, et al. Puerarin attenuates the endothelial-mesenchymal transition induced by oxidative stress in human coronary artery endothelial cells through PI3K/AKT pathway. Eur J Pharmacol. 2020;886:173472. doi: 10.1016/j.ejphar.2020.173472
- Baiyun R, Li S, Liu B, et al. Luteolin-mediated PI3K/AKT/Nrf2 signaling pathway ameliorates inorganic mercury-induced cardiac injury. Ecotoxicol Environ Saf. 2018;161:655-661. doi: 10.1016/j.ecoenv.2018.06.046
- Bai Y, Wang X, Zhao S, Ma C, Cui J, Zheng Y. Sulforaphane protects against cardiovascular disease via Nrf2 activation. Oxid Med Cell Longev. 2015;2015:407580. doi: 10.1155/2015/407580
- Gao HL, Yu XJ, Feng YQ, et al. Luteolin attenuates hypertension via inhibiting NF-κB-mediated inflammation and PI3K/Akt signaling pathway in the hypothalamic paraventricular nucleus. Nutrients. 2023;15(3):502. doi: 10.3390/nu15030502
- Sun XP, Wan LL, Yang QJ, Huo Y, Han YL, Guo C. Scutellarin protects against doxorubicin-induced acute cardiotoxicity and regulates its accumulation in the heart. Arch Pharm Res. 2017;40(7):875-883. doi: 10.1007/s12272-017-0907-0
- Fu Y, Sun S, Sun H, et al. Scutellarin exerts protective effects against atherosclerosis in rats by regulating the Hippo-FOXO3A and PI3K/AKT signaling pathways. J Cell Physiol. 2019;234(10):18131-18145. doi: 10.1002/jcp.28446
- Riemschneider S, Hoffmann M, Slanina U, Weber K, Hauschildt S, Lehmann J. Indol-3-carbinol and quercetin ameliorate chronic DSS-induced colitis in C57BL/6 mice by AhR-mediated anti-inflammatory mechanisms. Int J Environ Res Public Health. 2021;18(5):2262. doi: 10.3390/ijerph18052262
- Wei X, Meng X, Yuan Y, Shen F, Li C, Yang J. Quercetin exerts cardiovascular protective effects in LPS-induced dysfunction in vivo by regulating inflammatory cytokine expression, NF-κB phosphorylation, and caspase activity. Mol Cell Biochem. 2018;446(1-2):43-52. doi: 10.1007/s11010-018-3271-6
- Zhao H, Lin X, Chen Q, Wang X, Wu Y, Zhao X. Quercetin inhibits the NOX2/ROS-mediated NF-κB/TXNIP signaling pathway to ameliorate pyroptosis of cardiomyocytes to relieve sepsis-induced cardiomyopathy. Toxicol Appl Pharmacol. 2023;477:116672. doi: 10.1016/j.taap.2023.116672
- Chen D, Liang X, Zhang L, et al. E3 ubiquitin ligase FBXO32 promotes LPS-induced cardiac injury by regulating ANXA1/PI3K/AKT signaling. Inflammation. 2025;48(5):3396-3413. doi: 10.1007/s10753-025-02273-w
- Guan F, Du H, Li J, Ren H, Dong A. Quercetin alleviates LPS-stimulated myocardial injury through regulating ALOX5/PI3K/AKT pathway in sepsis. Cardiovasc Toxicol. 2024;24(10):1116-1124. doi: 10.1007/s12012-024-09901-1
- Xue X, Deng Y, Wang J, et al. Hydroxysafflor yellow A, a natural compound from Carthamus tinctorius L with good effect of alleviating atherosclerosis. Phytomedicine. 2021;91:153694. doi: 10.1016/j.phymed.2021.153694
- Zou J, Wang N, Liu M, et al. Nucleolin-mediated pro-angiogenic role of hydroxysafflor yellow A in ischaemic cardiac dysfunction: post-transcriptional regulation of VEGF-A and MMP-9. J Cell Mol Med. 2018;22(5):2692-2705. doi: 10.1111/jcmm.13552
- Min J, Wei C. Hydroxysafflor yellow A cardioprotection in ischemia-reperfusion injury mainly via Akt/hexokinase II independent of ERK/GSK-3β pathway. Biomed Pharmacother. 2017;87:419-426. doi: 10.1016/j.biopha.2016.12.113
- Qin GW, Lu P, Peng L, Jiang W. Ginsenoside Rb1 inhibits cardiomyocyte autophagy via PI3K/Akt/mTOR signaling pathway and reduces myocardial ischemia/reperfusion injury. Am J Chin Med. 2021;49(8):1913-1927. doi: 10.1142/S0192415X21500907
- Qin L, Fan S, Jia R, Liu Y. Ginsenoside Rg1 protects cardiomyocytes from hypoxia-induced injury through the PI3K/AKT/mTOR pathway. Pharmazie. 2018;73(6):349-355. doi: 10.1691/ph.2018.8329
- Wang Y, Zheng J, Xiao X, et al. Ginsenoside Rd attenuates myocardial ischemia/reperfusion injury by inhibiting inflammation and apoptosis through PI3K/Akt signaling pathway. Am J Chin Med. 2024;52(2):433-451. doi: 10.1142/S0192415X24500186
- Qi M, Wang Q, Sun R, et al. Astragaloside IV alleviates H2O2-induced mitochondrial dysfunction and inhibits mitophagy via PI3K/AKT/mTOR pathway. Cardiovasc Ther. 2025;2025:9549175. doi: 10.1155/cdr/9549175
- Yang P, Zhou Y, Xia Q, Yao L, Chang X. Astragaloside IV regulates the PI3K/Akt/HO-1 signaling pathway and inhibits H9c2 cardiomyocyte injury induced by hypoxia-reoxygenation. Biol Pharm Bull. 2019;42(5):721-727. doi: 10.1248/bpb.b18-00854
- Wei D, Xu H, Gai X, Jiang Y. Astragaloside IV alleviates myocardial ischemia-reperfusion injury in rats through regulating PI3K/AKT/GSK-3β signaling pathways. Acta Cir Bras. 2019;34(7):e201900708. doi: 10.1590/s0102-865020190070000008
- Chen XJ, Meng D, Feng L, et al. Protective effect of astragalosides on myocardial injury by isoproterenol in SD rats. Am J Chin Med. 2006;34(6):1015-1025. doi: 10.1142/S0192415X0600448X
- Monceaux K, Gressette M, Karoui A, et al. Ferulic acid, pterostilbene, and tyrosol protect the heart from ER-stress-induced injury by activating SIRT1-dependent deacetylation of eIF2α. Int J Mol Sci. 2022;23(12):6628. doi: 10.3390/ijms23126628
- Sahu R, Dua TK, Das S, De Feo V, Dewanjee S. Wheat phenolics suppress doxorubicin-induced cardiotoxicity via inhibition of oxidative stress, MAP kinase activation, NF-κB pathway, PI3K/Akt/mTOR impairment, and cardiac apoptosis. Food Chem Toxicol. 2019;125:503-519. doi: 10.1016/j.fct.2019.01.034
- Chen XJ, Liu SY, Li SM, et al. The recent advance and prospect of natural source compounds for the treatment of heart failure. Heliyon. 2024;10(5):e27110. doi: 10.1016/j.heliyon.2024.e27110
- Kim SH, Kee HJ, Zhou H, et al. Chlorogenic acid attenuates cardiac hypertrophy and fibrosis by downregulating galectin 3. Sci Rep. 2025;15(1):26925. doi: 10.1038/s41598-025-12220-0
- Wu X, Wang J, Li B, et al. Chlorogenic acid, rutin, and quercetin from Lysimachia christinae alleviate triptolide-induced multi-organ injury in vivo by modulating immunity and AKT/mTOR signal pathway to inhibit ferroptosis and apoptosis. Toxicol Appl Pharmacol. 2023;467:116479. doi: 10.1016/j.taap.2023.116479
- Ren BC, Zhang YF, Liu SS, et al. Curcumin alleviates oxidative stress and inhibits apoptosis in diabetic cardiomyopathy via Sirt1-Foxo1 and PI3K-Akt signalling pathways. J Cell Mol Med. 2020;24(21):12355-12367. doi: 10.1111/jcmm.15725
- Yu W, Qin X, Zhang Y, et al. Curcumin suppresses doxorubicin-induced cardiomyocyte pyroptosis via a PI3K/Akt/mTOR-dependent manner. Cardiovasc Diagn Ther. 2020;10(4):752-769. doi: 10.21037/cdt-19-707
- Yu W, Zha W, Ke Z, et al. Curcumin protects neonatal rat cardiomyocytes against high glucose-induced apoptosis via PI3K/Akt signalling pathway. J Diabetes Res. 2016;2016:4158591. doi: 10.1155/2016/4158591
- Chen X, Xie Q, Zhu Y, et al. Cardio-protective effect of tetrahydrocurcumin, the primary hydrogenated metabolite of curcumin in vivo and in vitro: induction of apoptosis and autophagy via PI3K/AKT/mTOR pathways. Eur J Pharmacol. 2021;911:174495. doi: 10.1016/j.ejphar.2021.174495
- Och A, Och M, Nowak R, Podgórska D, Podgórski R. Berberine, a herbal metabolite in the metabolic syndrome: the risk factors, course, and consequences of the disease. Molecules. 2022;27(4):1351. doi: 10.3390/molecules27041351
- Zhu F, Qian C. Berberine chloride can ameliorate the spatial memory impairment and increase the expression of interleukin-1β and inducible nitric oxide synthase in the rat model of Alzheimer’s disease. BMC Neurosci. 2006;7:78. doi: 10.1186/1471-2202-7-78
- Chen K, Li G, Geng F, et al. Berberine reduces ischemia/reperfusion-induced myocardial apoptosis via activating AMPK and PI3K-Akt signaling in diabetic rats. Apoptosis. 2014;19(6):946-957. doi: 10.1007/s10495-014-0977-0
- Cao Y, Shen T, Huang X, et al. Astragalus polysaccharide restores autophagic flux and improves cardiomyocyte function in doxorubicin-induced cardiotoxicity. Oncotarget. 2017;8(3):4837-4848. doi: 10.18632/oncotarget.13596
- Su H, Peng C, Liu Y. Regulation of ferroptosis by PI3K/Akt signaling pathway: a promising therapeutic axis in cancer. Front Cell Dev Biol. 2024;12:1372330. doi: 10.3389/fcell.2024.1372330
- Bai X, Wei H, Liu G, Li L. Astragalus polyphenols attenuates doxorubicin-induced cardiotoxicity by activating the PI3K/AKT/NRF2 pathway. PLoS One. 2025;20(2):e0319067. doi: 10.1371/journal.pone.0319067
- Elgendy IY, Pepine CJ. Heart failure with preserved ejection fraction: is ischemia due to coronary microvascular dysfunction a mechanistic factor? Am J Med. 2019;132(6):692-697. doi: 10.1016/j.amjmed.2018.12.038
- Santos JH, Quimque MTJ, Macabeo APG, et al. Enhanced oral bioavailability of the pharmacologically active lignin magnolol via Zr-based metal organic framework impregnation. Pharmaceutics. 2020;12(5):437. doi: 10.3390/pharmaceutics12050437
- Geng Q, Xu Y, Hu Y, et al. Progress in the application of organoids-on-a-chip in diseases. Organogenesis. 2024;20(1):2386727. doi: 10.1080/15476278.2024.2386727
