Introduction

The term cardiovascular disease (CVD) represents a broad range of diseases including heart disease, stroke, hypertension, hyperlipidemia, thromboembolism, coronary heart disease, congestive heart failure (CHF), hardening of the arteries, other circulatory system diseases etc. The published reports state that cardiovascular diseases are currently the leading cause of death especially in industrialized countries.¹ In addition to mortality, poorly managed CVD can lead to significant long-term disability from the complications of heart attacks, strokes, heart failure, and end-stage renal disease. CVD has become serious public health issue and hence requires greater attention to promote adequate awareness and treatment, both to health care providers and to the public. The growth of CVD in India further indicates that certain conditions like complicated hyperlipidemia, drug induced cardiotoxicity, atherosclerosis hasten the progress of disease and can cause various complications.² 

Cardiotoxicity includes a wide range of cardiac effects from small changes in blood pressure and arrhythmias to cardiomyopathy.  Drug-induced cardiotoxicity represents one of the most serious and major toxic effects induced by several chronically administered drugs. Cardiotoxicity accounted for 60% of all drugs withdrawn till date, which was mainly due to cardiac ischemia-related and arrhythmogenic side effects. The outcome of therapy is largely governed by precipitation of untoward effects which in turn may obstruct continuation of therapy. Drug-induced cardiotoxicity represents a major adverse effect of some common traditional antineoplastic agents. Doxorubicin (DOX) is one of the most potent anticancer agents, which has been reported to be associated development of cardiotoxicity in the form of cardiomyopathy and congestive heart failure in >50% of patients in last 10 years. Doxorubicin (DOX) has been reported to produce a multimodal cardiotoxic action, including impairment of mitochondrial metabolism, oxidative stress, disruption of calcium modulation and direct DNA damage.^3,4 This in turn promoted doxorubicin to be used as an inducing agent in experimental pharmacology. Thus, the current scenario advocates a need for novel agents with higher cardioprotective efficacy against doxorubicin induced cardiotoxicity.⁵

Randia dumetorum commonly known as madanphala belongs to the family Rubiacea.⁶ The fruits of Randia dumetorum have been documented for several pharmacological activities like antibacterial, antioxidant, anti-allergic, anti-inflammatory, analgesic, immunomodulatory activities etc.^7,8 In light of this, present study has been undertaken. 

Materials and methods

Plant material collection and authentication

Fruits of Randia dumetorum were procured from local market. The plant materials were taxonomically identified and authenticated. 

Preparation of extract

The powdered drug (100 gm) was extracted successively using a Soxhlet extractor with 200ml of ethanol. Extracts were filtered, concentrated and after complete solvent evaporation, each of these solvent extract was weighed and preserved at 5°C in an airtight bottle until further use.

Preliminary phytochemical screening of extract

The ethanolic extract of fruits of Randia dumetorum were analyzed for the presence of phytochemical constituents such as terpenoids, alkaloids, quinines, flavonoids, saponins, steroids and phenolic compounds using the standard qualitative phytochemical methods.⁹

Drugs and chemicals

All the drugs and chemicals of AR grade were procured from local vendor. 

Animals

Male Swiss albino mice (18-22gm) and Wistar albino rats (180-220gm) of either sex was procured from local vendor and were maintained at 25 ± 2° C and relative humidity of 45 to 55% and under standard environmental conditions (12 h light: 12 h dark cycle) at animal house. The animals had free access to food and water throughout study. Institutional Animal Ethical Committee approved the protocol. All the experiments were carried out between 9:00- 16:00 hour.

Ethical clearance

Institutional Animal Ethical Committee of D. Y. Patil College of Pharmacy, Akurdi, Pune approved the protocol.  

Preliminary acute toxicity test

Healthy adult male Swiss albino mice (18-22 g) were subjected to acute toxicity studies of ERD as per guidelines (AOT 425) suggested by the organization for economic cooperation and development (OECD-2000). The mice were observed continuously for 2 h for behavioural and autonomic profiles and for any sign of toxicity or mortality up to a period of seven days.^10,11 

Cardioprotective activity

Doxorubicin induced cardiotoxicity model

48 preselected rats were divided into 06 groups, each group consisting of 06 rats (Table 1).

Table 1: Experimental design

These rats were subjected to respective drug treatment for the period of 10 days along with intraperitoneal administration of doxorubicin (20mg/kg) from 8^th day.

On 10^th day, 60 minutes after dosing, following procedures were carried out.

Recording of blood pressure (hemodynamic parameters)

Estimation of serum and tissue parameters (oxidative biomarkers/antioxidant parameters)

Histopathological studies^12-14

Recording of hemodynamic parameters

The systolic and blood pressure was measured using non-invasive blood pressure measurement apparatus.¹² 

Estimation of serum parameters

The blood was collected from the retro orbital plexus of each rat. Serum was separated in a centrifuge at 7000 rpm for 15 minutes and lactate dehydrogenase (LDH), creatinine phosphokinase – MB isoenzyme (CKMB) levels were measured using standard kit according to the manufacturer’s instruction manual using auto analyzer.^13,14 

Estimation of tissue parameters (oxidative biomarkers/antioxidant parameters)

All rats were euthanized and hearts were removed and weighed, after squeezing out the blood, 02 hearts of randomly selected rats were sent for histopathological investigation while rest 04 hearts were processed & homogenized with 10% chilled TRIS hydrochloride buffer (10mM, pH 7.4) using tissue homogenizer at 7500 rpm for 15 minutes. The clear supernatant was used for the estimation of superoxide dismutase (SOD), reduced glutathione (GSH), and malonaldehyde (MDA) using standard kit.¹⁴ 

Histopathological studies

The cardiac tissue was dissected and excised from the isolated heart and washed with the normal saline, and stored in 10% buffered neutral formalin and then subjected to histopathological examination to evaluate the details of architecture in each group microscopically.^13,14

Data Analysis

Data obtained was subjected to statistical analysis of suitable parametric or non-parametric test using GraphPad InStat software, USA.

High Performance Thin Layer Chromatography (HPTLC) studies of ethanolic extract of Randia dumetorum fruit¹⁵

Instrumentation

HPTLC system of CAMAG, Muttenz, Switzerland, Anchrom Enterprises (I) Pvt. Ltd, Mumbai, consisting of sample applicator (Linomat 5), Twin trough chamber with lid (10×10 cm, CAMAG, Muttenz, Switzerland), UV cabinet (Aetron, Mumbai) with dual wavelength (254/366 nm) and the HPTLC photodocumentation (Aetron, Mumbai) was used for study.

Chromatographic conditions

The sample was spotted in the form of bands of width of 6 mm with a 100 µL sample syringe (Hamilton, Bonaduz, Switzerland) on precoated silica gel aluminium plate 60 F254 (5 cm ×10 cm) with 250 µm thickness (E. MERCK, Darmstadt, Germany) using a CAMAG Linomat 5 sample applicator (Switzerland). The slit dimensions 5 mm × 0.45 mm and scanning speed of 20 mm/sec was employed.

The linear ascending development was carried out in 10 cm×10 cm twin trough glass chamber (CAMAG, Muttenz, Switzerland) using Toluene: Ethyl acetate (7: 3 v/v) as mobile phase. The optimized chamber saturation time for mobile phase was 10 min. The length of chromatogram run was 8 cm and development time was approximately 15 min. TLC plates were dried in a current of air with the help of a hair drier.

Sample Preparation

10 mg of ethanolic extract of Randia dumetorum fruit was dissolved in 10 ml of ethanol. 10 µl volume of clear supernatant sample was applied on the TLC plate

Calculation of R_f Values

Plate was observed in the daylight, under UV light (254 and 366 nm). Retention factor (R_f) was calculated by following formula (Chatwal and Anand, 2004; Sethi and Charegaonkar, 1999).

R_f = A/B

A = distance between point of application and central point of spot of material being examined.

B = distance between the point of application and the mobile phase front.¹⁵ 

Results

Preliminary phytochemical screening

The results of preliminary phytochemical screening of ethanolic extract of fruits of Randia dumetorum (ERD) showed the presence of triterpenoids, glycosides, saponins, carbohydrates, flavonoids, tannins and proteins.

Preliminary acute toxicity test

Ethanolic extract of fruits of Randia dumetorum (ERD) was found to be safe and no mortality was observed up to 2000 mg/kg. 

Doxorubicin (DOX) induced cardiotoxicity model 

Recording of heamodynamic parameters

Table 2: Recording of heamodynamic parameters

Results were expressed as mean + SEM (n=6). Comparison between the groups was made by one-way analysis of variance (ANOVA) followed by One-way analysis of variance (ANOVA) followed by Bonferroni multiple comparisons test. ^***P<0.001 as compared to normal control. ^#P<0.05, ^##P<0.01, ^###P<0.001 as compared to DOX induced control.

The results of the study (Table No. 2) showed significant (P<0.001) decrease in the systolic as well as diastolic blood pressure in doxorubicin induction control group as compared to normal control groups. ERD was capable of overcome the doxorubicin induced decrease in the blood pressure and showed significant increase in the blood pressure dose dependently at doses 200 mg/kg (P<0.01), 400 mg/kg (P<0.001) and standard FF65 (P<0.001).   

Estimation of serum parameters

Table 3: Estimation of serum parameters

Results were expressed as mean + SEM (n=6). Comparison between the groups was made by one-way analysis of variance (ANOVA) followed by One-way analysis of variance (ANOVA) followed by Bonferroni multiple comparisons test. ^***P<0.001 as compared to normal control. ^#P<0.05, ^##P<0.01, ^###P<0.001 as compared to DOX induced control

The results of the study (Table No. 3) showed significant (P<0.001) increase in the LDH as well as CKMB in doxorubicin induction control group as compared to normal control groups. ERD produced significant and dose dependant decrease in both LDH and CKMB at doses 200 mg/kg (P<0.01), 400 mg/kg (P<0.001) and standard FF65 (P<0.001).  

Estimation of tissue parameters

Table 4: Estimation of tissue parameters

Results were expressed as mean + SEM (n=6). Comparison between the groups was made by one-way analysis of variance (ANOVA) followed by One-way analysis of variance (ANOVA) followed by Bonferroni multiple comparisons test. ^***P<0.001 as compared to normal control. ^#P<0.05, ^##P<0.01, ^###P<0.001 as compared to DOX induced control

The results (Table No. 4) showed that doxorubicin administration caused significant elevation (P<0.001) of tissue malondialdeyhde (MDA) levels as well as significant (P<0.001) decrease in tissue levels of superoxide dismutase (SOD) and reduced glutathione (GSH) as compared to normal control group. ERD reverted these alterations significantly and dose dependently at doses 200 mg/kg (P<0.01), 400 mg/kg (P<0.001) and standard FF65 (P<0.001)  in comparison with doxorubicin induced control group.

Determination of heart weight, body weight and heart weight to bodyweight ratio

Table 5: Determination of heart weight, body weight and heart weight to bodyweight ratio

Results were expressed as mean + SEM (n=6). Comparison between the groups was made by one-way analysis of variance (ANOVA) followed by One-way analysis of variance (ANOVA) followed by Bonferroni multiple comparisons test. ^***P<0.001 as compared to normal control. ^#P<0.05, ^##P<0.01, ^###P<0.001 as compared to DOX induced control.

The results of the investigation (Table No. 5) indicated a significant decrease in heart weight as well as body weight in doxorubicin induced control group as compared to normal control group. The groups treated with extract successfully attenuated the reduction in weight produced by the doxorubicin and exhibited significant and dose dependant increase in the body weight at doses 200 mg/kg (P<0.01), 400 mg/kg (P<0.001) and standard FF65 (P<0.001) in comparison with doxorubicin induced control group. There was no significant difference found in the heart weight to body weight ratio in between all the groups. 

Histopathological studies of cardiac tissue

Rats exposed to doxorubicin showed interfibrillar hemorrhages, congestion, and focal areas of disrupted cardiac muscle fibers, hyperemia, cellular infiltration and necrosis, parenchymatous degeneration, eosinophilic degeneration, interstitial edema in the heart tissue. Pre-treatment with extract ERD 400 mg/kg and standard FF65 effeciently amleliorated these alterations showing protective activity against doxorubicin induced cardiotoxicity (Figure 1). 

Figure 1: Effect of Ethanolic extract of fruits of Randia dumetorum (ERD) doxorubicin induced changes in heart tissue. Click here to view figure

Representative photomicrographs (H & E stain) of liver tissue (A) Normal control (B) Positive control (C) ERD 400 (D) FF65. Rats exposed to doxorubicin showed interfibrillar hemorrhages, congestion, and focal areas of disrupted cardiac muscle fibers , hyperemia, cellular infiltration and necrosis, parenchymatous degeneration, eosinophilic degeneration, interstitial edema in the heart tissue. Pre-treatment with extract ERD 400 mg/kg and standard FF65 effeciently amleliorated these alterations. 

High Performance Thin Layer Chromatography (HPTLC) studies of ethanolic extract of Randia dumetorum fruit¹⁵

Figure 2: Ethanolic extract of fruits of Randia dumetorum at 366 nm, Volume applied 10 ml.  Click here to view figure

Figure 3: Ethanolic extract of fruits of Randia dumetorum at 254 nm, Volume applied 10 ml. Click here to view figure

The Band 3 at R_f Value 0.32 was scratched and subjected to structure elucidation.

Figure 4: Ethanolic extract of fruits of Randia dumetorum at visible, Volume applied 10 ml. Click here to view figure

The band at R_f Value 0.32 was scratched, extracted with ethanol and evaporated to dryness (The process required semipreparative TLC to achieve sufficient amount) for further analysis by IR, NMR and Mass Spectrometry.

Spot at R_f Value – 0.32

Figure 5: FT-IR Spectrum of compound at Rf – 0.32  Click here to view figure

Table 6: Interpretation of NMR spectrum

Figure 6: LC-MS A) Chromatograph and B) Spectrum of compound at Rf – 0.32. Click here to view figure

Figure 7. NMR Spectrum of compound at Rf – 0.32 Click here to view figure

Table 7: Interpretation of NMR spectrum

 Probable structure of the isolated compound is as below

Figure 8: 2-(3,5-dihydroxyphenyl)-3,4-dihydro-2H-chromene-3,5,7-triol. Click here to view figure

Discussion

Drug induced cardiotoxicity is another concern which is becoming important day by day due to the development and use of various drugs.¹⁶ Doxorubicin is the most widely used chemotherapeutic agents hence its cardiotoxicity is of paramount concern.¹⁷ This most frequent and serious adverse effect (cardiotoxicity) is commonly observed in doxorubicin-treated cancer surviving patients.¹⁶ This side effect may restrict the use of drugs irrespective of their potential as a therapeutic agent.¹⁸ Considering therapeutic potential of doxorubicin as an anticancer agent, it is not affordable to stop this therapy due to associated to cardiotoxicity, rather complimentary therapy that can selectively reduce or prevent the cardiotoxicity is the most appropriate solution.^19,17

Herbal medicines play considerable role in health care to a large proportion of world’s population and have been regarded as component of cultural heritage of various tribes. Since these drugs are from natural origin hence are documented for reducing the risks of cardiac ailments by several mechanisms by virtue of presence of several phytoconstituents.²⁰

Randia dumetorum is such an indigenous medicinal plant which is traditionally claimed to be useful in the treatment of cardiovascular diseases but haven’t yet been adequately documented, hence its cardioprotective activity was evaluated against doxorubicin induced cardiotoxicity.²¹

The traditional claim, scientific observations and presence of phytochemicals have close relationship towards the actual therapeutic outcome.^22,11 In light of this, the preliminary phytochemical analysis of ethanolic extracts of fruits of Randia dumetorum was carried out. The extract showed the prominent presence of triterpenoids, glycosides, saponins, carbohydrates, flavonoids, tannins and proteins. After the confirmation of phytochemical profile and its pharmacological importance, then toxicity profile testing becomes highly essential to confirm its safety before going for actual exploration of its pharmacological activity. Toxicity profile testing is critically important for any therapeutic medication for confirmation of the extent of its therapeutic utilization.¹⁰ Hence acute oral toxicity test was conducted for ERD extract for confirmation of its safety. The results of acute oral toxicity studies of ERD revealed that both these extracts are safe up to 2000 mg/kg which is highest prescribed limit as per this test. Thus, ERD fulfilled the safety criteria before the assessment of preclinical activity. Based upon these findings and available literature, the three different doses i.e., 100, 200 and 400 mg/kg of extract were evaluated for cardioprotective activity against doxorubicin induced cardiotoxicity.

The results of current study were quite encouraging. The significant restoration of decreased systolic as well as diastolic blood pressure by the extract exhibited its potential from basic step. It has been reported that approximately 60% of patients with cardiotoxicity usually experience fluctuations in blood pressure as first symptom which if attended well then further complications do not occur at all.²³ Moreover, as on date, modern therapy does not have any satisfactory remedy to elevate this lowered blood pressure hence simple fluctuation may result in serious condition.²⁴ Accordingly, ERD was found to be effective which is a primary but important outcome of the study.

The damage to cardiomyocytes indicating anatomical manipulation is the next step of cardiotoxicity. This damage is usually indicated by the elevated levels of LDH and CKMB.²⁵ In this connection, ERD showed significant restoration of elevated levels of serum LDH as well as CKMB. ERD showed the presence of triterpenoids and glycosides which are already reported to control CKMB.^26,27

It is well documented that about 85% of patients who are on doxorubicin therapy report alterations in these two markers and out of which almost 25 % of patients need to switch to other therapy.²⁸ In the patients with mild elevation in LDH which do not need to stop or switch from doxorubicin therapy are still under risk zone. The patients upon consumption of aspirin, alcohol, exposure to stress and strenuous exercise may suddenly lead to easy shoot up of levels.²⁹ Hence the results obtained for ERD are highly valuable to continue doxorubicin therapy with minimum risk.  

An increase of free radicals and a decrease in the activity of endogenous antioxidants in the myocardium is believed to play important roles in the pathogenesis of doxorubicin-induced cardiotoxicity and subsequent heart failure.³⁰ In light of this, the significant modulations in antioxidant parameters such as malondialdeyhde (MDA), superoxide dismutase (SOD) and reduced glutathione (GSH) by ERD were recorded. These promising reports are suggestive of role of antioxidant potential of the ERD. The elevated MDA levels is usually observed in cancer patients which further increases with doxorubicin therapy and can worsen the conditions rapidly. This is one of the best examples of limitations of therapy due to drug induced toxicities.³¹ Hence the significant reduction in the MDA levels by both the extracts which is not only useful to halt doxorubicin induced toxicity but can speed up the recovery too. This also suggest possible use of the ERD as an adjuvant therapy to doxorubicin in cancer patient. The significant modulation in GSH and SOD which are part of body’s antioxidant mechanism further endorse the role of ERD in preventing doxorubicin induced toxicity.³²

It is also documented that GSH imbalance is seen in various diseases including cancer. Further this imbalance is more intense with increasing age making the conditions more complicated.³³ This further makes doxorubicin therapy more.³⁰ On this background, significant reduction in GSH levels with the pre-treatment of extracts not only useful to prevent doxorubicin induced toxicity but also to slow down the natural deterioration due to the existing cancer. This dual effect is an ideal achievement of this study. Both the extracts have already been reported for its anti-inflammatory activity. On the contrary, continuous inflammation is one of the reasons for occurrence of cancer and aggravation of already existed cancer. Hence, addition of ERD as an adjuvant therapy as proposed above can have an add on benefit to restrict the role of inflammatory mediators in the progress of the cancer.³³ This multistep action is most important advantage over the modern medicine.³⁴

Cardiomyocyte death, decrease in myocyte volume and its number leading to decrease in heart weight is another toxic effect of doxorubicin. In the current study, this toxic effect could not be modulated by the ERD suggesting non-utility for this type of damage.³⁵ Reducing heart weight can initiate the series of adverse events like reduction in blood pressure followed by difficulty in pumping and then reflex elevation in blood pressure which in due course of usually time results in multiple organ failure.³⁶

Here at initial stage, ERD may provide some relief by restoring reduced dropped blood pressure but cannot offer any protection over subsequent events. Thus, this study also reported the inability of ERD to protect or reverse the critical situation that arises due to the death of cardiomyocytes.³⁷

Histopathology is an important tool to know extent of tissue damage in pathophysiology. As a general rule, when the tissue architecture shows adverse changes, it indicates the progressive step of any diseased condition. Moreover, when these initial reversible changes become irreversible then condition become more critical.³⁸ The drug which prevents or delays the involvement of the tissue, halt process at reversible stage or delays to go into the irreversible stage is found to be effective.³⁹ In this regard, ERD showed a widespread improvement in histopathology suggesting their role even in progressive stage of toxicity. Amelioration of necrosis by ERD is an indication to keep pathological changes to reversible nature which is the most valuable result. This property of the ERD makes it suitable to provide wider protection and ensure patients quality of life for longer period which is one of the most important expectations in the case of cardiotoxicity.^40,39   

The HPTLC analysis of ERD was carried out to identify the phytoconstituent responsible for the cardioprotective activity. The results of study revealed the prominent presence of a compound namely 2-(3,5-dihydroxyphenyl)-3,4-dihydro-2H-chromene-3,5,7-triol as pharmacologically important phytoconstituent. The isolation of these phytoconstituents is an important concluding result of the study and cardioprotective activity of ERD may be attributed to this phytoconstituent.⁴¹

The overall results thus showed a potent and widespread protective activity of ethanolic extract of fruits of Randia dumetorum against doxorubicin induced cardiotoxicity indicating its use in the cancer patients for development of cardioprotective treatment especially for doxorubicin-treated cancer survivors.⁴² 

Conclusion

The present study documented the cardioprotective activity of ethanolic extract of fruits of Randia dumetorum against doxorubicin induced cardiotoxicity. The extract offered wide range of protection through control of heamodynamic parameters, modulation of various markers, imparting antioxidant action and thereby improvement in histopathology as well showing potent cardioprotective activity against doxorubicin induced cardiotoxicity. The multistep putative action of ethanolic extract of fruits of Randia dumetorum may be attributed to the prominent phytoconstituents namely 2-(3,5-dihydroxyphenyl)-3,4-dihydro-2H-chromene-3,5,7-triol revealed in the study.

 Conflict of Interest

There are no conflict of interest.

Funding Sources

There is no funding sources.

References

1. Assimes TL and Roberts R (2016) Genetics: implications for prevention and management of coronary artery disease. Journal of the American College of Cardiology 68 (25): 2797–2818.
   CrossRef
2. Mozaffarian D, Benjamin EJ, Go AS, et al. (2016) Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 133 (4): e38–360.
   CrossRef
3. Zhou S, Palmeira CM, Wallace KB. Doxorubicin-induced persistent oxidative stress to cardiac myocytes. Toxicol Lett 2001;121:151–7.
   CrossRef
4. Zhang J, Herman EH, Douglas PC, Ferrans VJ. Comparison of the protective effects of amifostine and dexrazoxane against the toxicity of doxorubicin in spontaneously hypertensive rats. Cancer Chemother Pharmacol 2000;45:329–34.
   CrossRef
5. Shah SMA, Akram M, Riaz M, Munir N, Rasool G. Cardioprotective Potential of Plant-Derived Molecules: A Scientific and Medicinal Approach. Dose Response. 2019;17(2):1559325819852243.
   CrossRef
6. Ayush Kumar Garg et al.,2019, Madanaphala (Randia dumetorum): A Pharmacological and Pharmacognostical Review. Int J Recent Sci Res. 10(04), pp. 32061-32064.
7. Pooja Rani and Subash Sahu. 2019. “A critical review on madanphala (Randia dumetorum (Retz) Poir.)”. Ayushdhara 6 (3):2199-2206.
8. Ghosh D., Thejomoorthy P., Veluchamy. Anti-inflammatory and analgesic activities  of  oleanolic  acid  3-/3-  Glucoside  (RDG-1)  from Randia dumetorum (Rubiaceae). Indian J. Pharmacol. 1983; 4: 31-340.
9. Nadkarni KM, editor. Indian Materia Medica Vol. 1. Mumbai: Bombay Popular Prakashan Pvt. Ltd; 1976.
10. OECD Guideline for The Testing of Chemicals: Guidance document on acute oral toxicity. Environmental health and safety monograph series on testing and assessment 2000.
11. Vyawahare Neeraj S, Pujari Rohini R, Kagathara Virendra G, Gangurde Prajakta R, Bodhankar Subhash L, Hadambar Avinash A. Central Nervous System Activity of Argyreia speciosa.” Journal of Pharmaceutical Research. 2009;8(3):152-158.
    CrossRef
12. Gupta SK, Vyawahare NS, Kagathara VG, Patil MN, Pujari RR. Assessment of antihypertensive activity of novel synthetic hybrid compound on 2K1C induced hypertensive rats. Pharmacologyonline. 2009;2:273-80.
13. Pujari RR, Bandawane DD. Protective Effect of 2-Pyrocatechuic Acid on 5-Fluorouracil Induced Cardiotoxicity in Wistar Rats. Latin American Journal of Pharmacy. 2019 Jan 1;38(11):2266-71.
14. Nagi MN, Mansour MA. Protective effect of thymoquinone against doxorubicin–induced cardiotoxicity in rats: A possible mechanism of protection. Pharmacological research. 2000 Mar 1;41(3):283-9.
    CrossRef
15. Chatwal G. Sham KA. Instrumental methods of chemical analysis. 5th ed. Himalaya publishing house: New Delhi (2002) 2.566- 2.570
16. Cai, F., Antonio, M. & Luis, F. Anthracycline-Induced cardiotoxicity in the chemotherapy treatment of breast cancer: Preventive strategies and treatment (Review). Mol. Clin. Oncol. 11, 15–23 (2019).
    CrossRef
17. Pandey, S., Kuo, W.-W. & Shen, C.-Y. IGF-IIRα is a novel stress-inducible contributor to cardiac damage underpinning doxorubicin-induced oxidative stress and perturbed mitochondrial autophagy. Am. J. Physiol. Physiol. 1, C235–C243 (2019).
    CrossRef
18. Pai VB, Nahata MC. Cardiotoxicity of chemotherapeutic agents. Incidence, treatment and prevention. Drug Safety 2000;22:263–302.
    CrossRef
19. Cappetta, D., De Angelis, A. & Sapio, L. Oxidative stress and cellular response to doxorubicin: A common factor in the complex milieu of anthracycline cardiotoxicity. Oxid. Med. Cell. Longev. 15, 20 (2017).
    CrossRef
20. Shah SMA, Akram M, Riaz M, Munir N, Rasool G. Cardioprotective Potential of Plant-Derived Molecules: A Scientific and Medicinal Approach. Dose Response. 2019;17(2):1559325819852243.
    CrossRef
21. Thakur, Shifali, Hemlata Kaurav, and Gitika Chaudhary. 2021. “A Review on Woodfordia Fruticosa Kurz (Dhatki): Ayurvedic, Folk and Modern Uses”. Journal of Drug Delivery and Therapeutics 11 (3), 126-31.
    CrossRef
22. Jawaid T, Argal S, Singh S. Botanicals and herbs: A traditional approach in treatment of epilepsy. J Pharm Res. 2011;4:1138-1140.
23. Colussi, G.; Catena, C.; Novello, M.; Bertin, N.; Sechi, L.A. Impact of omega-3 polyunsaturated fatty acids on vascular function and blood pressure: Relevance for cardiovascular outcomes. Nutr. Metab. Cardiovasc. Dis. 2017, 27, 191–200.
    CrossRef
24. Stull, A.; Cash, K.; Champagne, C.; Gupta, A.; Boston, R.; Beyl, R.; Cefalu, W.T. Blueberries improve endothelial function, but not blood pressure, in adults with metabolic syndrome: A randomized, double-blind, placebo-controlled clinical trial. Nutrients 2015, 7, 4107–4123.
    CrossRef
25. Sergazy, S., Shulgau, Z., Fedotovskikh, G. et al. Cardioprotective effect of grape polyphenol extract against doxorubicin induced cardiotoxicity. Sci Rep 10, 14720 (2020).
    CrossRef
26. Omar, S.H. Cardioprotective and neuroprotective roles of oleuropein in olive. Saudi Pharm. J. 2010, 18,111–121.
    CrossRef
27. Anuradha, C.V. Phytochemicals targeting genes relevant for type 2 diabetes. Can. J. Physiol. Pharmacol. 2013, 91, 397–411.
    CrossRef
28. Roth, Gregory & Mensah, George & Johnson, Catherine & Banach, Maciej & Kimokoti, Ruth & Jóźwiak, Jacek & Murray, Christopher & Fuster, Valentin & Derseh, Behailu & Rojková, Tereza & Jeemon, Panniyammakal & Renzaho, Andre. (2020). Global Burden of Cardiovascular Diseases and Risk Factors, 1990–2019: Update From the GBD 2019 Study. Journal of the American College of Cardiology.
29. Takemura G, Fujiwara H. 2007. Doxorubicin-induced cardiomyopathy from the cardiotoxic mechanisms to management. Prog Cardiovasc Dis 49:330–352.
    CrossRef
30. Menna P, Recalcati S, Cairo G, Minotti G. 2007. An introduction to the metabolic determinants of anthracycline cardiotoxicity. Cardiovasc Toxicol 7:80–85
    CrossRef
31. Wojnowski L, Kulle B, Schirmer M, Schluter G, Schmidt A, Rosenberger A, Vonhof S, Bickeboller H, Toliat MR, Suk EK, Tzvetkov M, Kruger A, Seifert S, Kloess M, Hahn H, Loeffler M, Nurnberg P, Pfreundschuh M, Trumper L, Brockmoller J, Hasenfuss G. 2005. NAD(P)H oxidase and multidrug resistance protein genetic polymorphisms are associated with doxorubicin-induced cardiotoxicity. Circulation 112:3754–3762.
    CrossRef
32. Zhang, H.; Tsao, R. Dietary polyphenols, oxidative stress and antioxidant and anti-inflammatory effects. Curr. Opin. Food Sci. 2016, 8, 33–42.
    CrossRef
33. Duthie, G.; Duthie, S.; Kyle, J. Plant polyphenols in cancer and heart disease: Implications as nutritional antioxidants. Nutr. Res. Rev. 2000, 23, 79–106.
    CrossRef
34. Myung, S.K.; Ju, W.; Cho, B.; Oh, S.W.; Park, S.M.; Koo, B.K.; Park, B.J. Efficacy of vitamin and antioxidant supplements in prevention of cardiovascular disease: Systematic review and meta-analysis of randomized controlled trials. BMJ 2013, 346, 10–21.
    CrossRef
35. Estevez MD, Wolf A, Schramm U. 2000. Effect of PSC 833, verapamil and amiodarone on adriamycin toxicity in cultured rat cardiomyocytes. Toxicol In Vitro 14:17–23.
    CrossRef
36. Ronchi, S.N.; Brasil, G.A.; Nascimento, A.M.; Lima, E.M.; Scherer, R.; Costa, H.B.; Romão, W.; Boëchat, G.A.P.; Lenz, D.; Fronza, M.; et al. Phytochemical and in vitro and in vivo biological investigation on the antihypertensive activity of mango leaves (Mangifera indica L.). Ther. Adv. Cardiovasc. Dis. 2015, 9, 244–256.
    CrossRef
37. Zuppinger C, Timolati F, Suter TM. 2007. Pathophysiology and diagnosis of cancer drug induced cardiomyopathy. Cardiovasc Toxicol 7:61–66.
    CrossRef
38. Mortensen SA, Olsen HS, Baandrup U: Chronic anthracycline cardiotoxicity: haemodynamic and histopathological manifestations suggesting a restrictive endomyocardial disease. Br Heart J 1986;55: 274-282.
    CrossRef
39. Cardinale D, Colombo A, Lamantia G, et al: Anthracycline-induced cardiomyopathy: clinical relevance and response to pharmacologic therapy. J Am Coll Cardiol 2010;55:213-220.
    CrossRef
40. Arola OJ, Saraste A, Pulkki K, et al: Acute doxorubicin cardiotoxicity involves cardiomyocyte apoptosis. Cancer Res 2000; 60:1789-1792.
41. Zhou JM, Xu ZL, Li N, Zhao YW, Wang ZZ, and Xiao W (2016) Identification of cardioprotective agents from traditional Chinese medicine against oxidative damage. Mol Med Rep 14:77 – 88.
    CrossRef
42. Peng X, Chen B, Lim CC, et al: The cardiotoxicology of anthracycline chemotherapeutics: translating molecular mechanism into preventative medicine. Mol Interv 2005;5:163-171.
    CrossRef