Unconventional mechanisms of resveratrol in atherosclerosis prevention and management

Abstract

Atherosclerosis is a progressive inflammatory disease and a major contributor to cardiovascular disease. Resveratrol (RES), a polyphenolic compound found in grapes and red wine, has been widely investigated for its protective effects on cardiovascular health. This review summarizes the mechanisms through which RES attenuates atherosclerosis, including its anti-inflammatory, antioxidant, and lipid-modulating effects. Experimental evidence indicates that RES inhibits nuclear factor kappa-light-chain-enhancer of activated B cells signaling, thereby reducing the expression of adhesion molecules such as vascular cell adhesion molecule-1 and intercellular adhesion molecule-1 and limiting immune cell infiltration into the arterial wall. Additionally, it counteracts oxidative stress by enhancing antioxidant enzyme activity and preventing low-density lipoprotein oxidation, a key event in foam cell formation. RES also promotes cholesterol efflux through adenosine triphosphate-binding cassette transporters, supporting high-density lipoprotein-mediated reverse cholesterol transport. Findings from in vitro, animal, and clinical studies suggest that RES can reduce atherosclerotic plaque development, improve endothelial function, and modulate lipid metabolism.

Key Words: Resveratrol; Atherosclerosis; Endothelial dysfunction; Foam cells; Inflammation; Gut microbiota

Core Tip: Resveratrol (RES) is a dietary polyphenol with pleiotropic anti-atherosclerotic actions that extend beyond conventional lipid lowering and antioxidant effects. This review synthesizes experimental evidence showing how RES stabilizes the endothelial barrier, remodels gut microbiota and bile acid metabolism, inhibits transforming growth factor-extracellular signal-regulated kinase signaling, modulates connexin 43 and phosphatase and actin regulator-1, and suppresses proinflammatory cytokine and smooth muscle cell migration pathways. By mapping these unconventional molecular targets, we highlight RES as a multi-target candidate for preventing plaque formation and promoting vascular homeostasis.

INTRODUCTION

Resveratrol (RES) is a natural polyphenolic compound found in grapes, berries, and other dark-skinned fruits[1]. RES has been reported to exert beneficial effects in cancer, neurological, hepatic, and cardiovascular diseases. RES has been shown to exert protective effects against atherosclerosis. Atherosclerosis is a chronic inflammatory disease of the arterial wall that is associated with substantial morbidity and mortality[2]. In the initial stages of atherosclerosis, circulating monocytes adhere to endothelial cells and migrate into the subintimal space, where they differentiate into macrophages[3]. These macrophages then take up lipids, particularly oxidized low-density lipoprotein (oxLDL), and acquire a foam cell phenotype, forming fatty streaks[3]. Vascular smooth muscle cells (VSMCs) then migrate into the intima and proliferate, producing extracellular matrix components[4]. In the advanced stages of the disease, plaques may develop a stable fibrous cap that isolates them from the surrounding vessel environment. Plaque destabilization occurs when the fibrous cap is depleted and ruptures, a process driven by matrix metalloproteinases (MMPs), which promote the breakdown of the extracellular matrix. This can lead to the narrowing of the blood vessel lumen, restricting blood flow and causing ischemia. RES exerts anti-atherosclerotic effects through several unconventional mechanisms, including inhibition of the aryl hydrocarbon receptor (AHR)[5], attenuation of trimethylamine-N-oxide (TMAO)-induced atherosclerosis, inhibition of the transforming growth factor (TGF)/extracellular regulated protein kinases (ERK) signaling pathway, upregulation of endothelial nitric oxide synthase (eNOS), and suppression of interleukin (IL)-18 expression, among others. This review focuses on unconventional pathophysiological mechanisms through which RES may modulate atherosclerosis development and plaque progression.

Previous reviews on RES and atherosclerosis have mainly focused on its classical antioxidant, anti-inflammatory, and lipid-lowering properties and often summarize mechanisms in a relatively fragmented manner. In contrast, the present minireview concentrates on unconventional, recently described pathways - including AHR/sarcoma (Src)-dependent regulation of endothelial permeability[6,7], gut microbiota-TMAO-bile acid (BA) signaling, TGF-β/ERK-mediated vascular remodeling, and gene regulatory targets such as phosphatase and actin regulator-1 (PHACTR1) - and integrates them into four mechanistic axes: Gut microbiota and metabolism, endothelial function, vascular wall remodeling, and immune and foam cell responses. By organizing these emerging data into a network-based framework, we highlight RES as a multi-target systems modulator in atherosclerosis rather than a single-target antioxidant, thereby providing a differentiated perspective compared with prior reviews.

LITERATURE SEARCH

The literature search was conducted using MEDLINE, EMBASE, Web of Science, Scopus, ClinicalTrials.gov, Ovid, and PubMed as electronic databases. Studies were identified using combinations of the following search terms: “Resveratrol”, “RES”, “RSV”, “atherosclerosis”, and randomized controlled trial as a publication type, from database inception to March 2025. We also screened the reference lists of the retrieved articles to identify additional relevant studies. No restrictions for language or geographic location were applied.

UNCONVENTIONAL MECHANISMS

While conventional therapeutic approaches primarily rely on lipid-lowering agents and anti-inflammatory drugs, RES additionally targets unconventional molecular pathways, including AHR/Src-dependent endothelial barrier regulation, gut microbiota-mediated TMAO metabolism, and TGF/ERK signaling. Moreover, studies suggest that RES affects foam cell formation, oxidative stress, and monocyte adhesion through complex gene regulatory mechanisms, including its effects on PHACTR1 and connexin 43 (Cx43)[7]. These findings suggest that RES could play a key role in preventing and managing atherosclerosis. The following sections summarize mechanistic evidence for these unconventional targets of RES in atherosclerosis.

Src kinase regulates intracellular signaling pathways, particularly those controlling endothelial cell permeability. It plays a crucial role in cadherin-dependent cell-to-cell adhesion, particularly through vascular endothelial (VE)-cadherin, which is essential for maintaining endothelial barrier integrity and controlling permeability changes[8]. VE-cadherin dysregulation contributes to endothelial barrier dysfunction, which in turn plays a major role in atherosclerosis, a leading cause of cardiovascular disease-related mortality[9]. Thus, increased Src kinase activity promotes disruption of cell-cell contacts, making this pathway a critical regulator of endothelial permeability. Indoxyl sulfate (IS) is a tryptophan-derived uremic toxin that exerts harmful cardiovascular effects by inducing oxidative stress and endothelial dysfunction through AHR activation[10]. Assefa et al[11] investigated the anti-atherosclerotic effects of RES in bovine aortic endothelial cells and identified the AHR as a key target. Activation of AHR by its ligands has been linked to endothelial dysfunction. When a ligand binds to AHR, Src kinase is activated through its release from the AHR complex. In that study, IS impaired cell survival and increased endothelial permeability by activating AHR/Src signaling and disrupting VE-cadherin-mediated junctions[11]. RES inhibited IS-induced Src activation and VE-cadherin disruption, thereby reducing endothelial hyperpermeability through the AHR/Src-dependent pathway[11]. Moreover, RES treatment significantly improved transendothelial electrical resistance in IS-injured cells, indicating its potential to restore the endothelial monolayer and preserve membrane integrity[11].

A recent study discovered that TMAO, a metabolite of choline, is a significant risk factor for developing atherosclerosis[12]. TMAO production depends on the gut microbiota, which first converts dietary choline into trimethylamine (TMA); TMA is then oxidized to TMAO by hepatic flavin monooxygenase enzymes[13]. Therefore, the gut microbiota is an important factor in the progression of TMAO-induced atherosclerosis. TMAO has also been shown to promote atherosclerosis by altering cholesterol metabolism, mainly through inhibition of hepatic BA synthesis. The liver synthesizes primary BAs from cholesterol, which are subsequently metabolized by the gut microbiota into secondary BAs through intestinal processes such as deconjugation, dehydrogenation, and dihydroxylation[14,15]. A negative-feedback loop involving the activation of the nuclear farnesoid X receptor (FXR) in the liver and ileum controls this process. Several studies have shown that gut microbiota modulate hepatic BA synthesis and secondary BA metabolism by altering the enterohepatic FXR-fibroblast growth factor 15 axis[16]. Chen et al[17] examined the role of gut microbiota in mediating the protective effects of RES against atherosclerosis in C57BL/6J and apolipoprotein E (ApoE)-/- mice. The authors concluded that RES reduced TMAO levels by suppressing gut microbial TMA production through gut microbiota remodeling, thereby attenuating TMAO-induced atherosclerosis[17]. Additionally, RES-induced remodeling of gut microbiota increased the conversion of conjugated BAs to unconjugated BAs and enhanced fecal BA excretion[17]. In turn, this RES-induced fecal BA loss reduced BA levels in the ileum, thereby inhibiting the ileal FXR-fibroblast growth factor 15 axis[17]. This suppression then upregulates cholesterol 7-α-hydroxylase expression in the liver, promoting hepatic BA synthesis and supporting cholesterol homeostasis, ultimately mitigating atherosclerosis.

Guo et al[18] explored the ability of RES to inhibit the TGF/ERK signaling pathway and thereby ameliorate atherosclerosis. TGF-β is a multifunctional cytokine that regulates numerous cellular processes. The TGF-β receptor complex activates both suppressor of mother against decapentaplegic (SMAD) and non-SMAD signaling pathways[18]. The extracellular signal-regulated kinase ERK pathway is a key non-SMAD signaling cascade that controls cellular functions and contributes to the development of numerous diseases[19]. The TGF/ERK signaling pathway is responsible for cell and tissue differentiation in the body and plays a role in development of cardiovascular diseases. This pathway promotes adventitial fibroblast proliferation, MMP, endothelial-to-mesenchymal transition, VSMC proliferation, fibrosis, inflammation and biglycan synthesis. TGF-β1 stimulates the expression of MMPs through ERK1/2 signaling pathway activation. MMPs contribute to atherosclerosis progression by promoting VSMC migration, degrading extracellular matrix, and modulating plaque stability[20]. Adventitial fibroblast plays a critical role in neointima formation and vascular proliferation and can differentiate into myofibroblasts that can migrate to the vascular intima and form atherosclerotic plaques. RES exerts substantial anti-atherosclerotic effects by inhibiting the TGF/ERK signaling pathway[18], thereby attenuating atherosclerosis and related cardiovascular disease.

Previous studies have highlighted the importance of macrophage-derived foam cells in the formation of atherosclerotic plaques[21]. Enhanced uptake of oxLDL and impaired cholesterol efflux are key determinants of macrophage-derived foam cell formation[21]. OxLDL uptake in macrophages are controlled by cluster differentiation and scavenger receptor A (SR-A)[22]. Moreover, SR-BI and adenosine triphosphate-binding cassette transporter G1 play a beneficial role in cholesterol efflux in macrophages. Numerous studies reported that RES inhibits atherosclerosis formation by modulating macrophage inflammatory signaling, including decreasing NLR family pyrin domain containing 3 inflammation activation and reducing IL-1beta secretion[23]. In vivo, RES has been associated with reduced atherosclerotic lesion formation in hyperlipidemic models[24]. Beyond macrophages, hepatic inflammatory signaling can also amplify atherosclerosis progression[25]. Hong et al[26] investigated trans-3,5,4′-trimethoxystilbene (TMS), a RES derivative, and demonstrated its protective effects against atherosclerosis[26]. ApoE knockout mice were fed a high-cholesterol diet and randomized to receive TMS or control treatment[26]. Additionally, TMS inhibited intracellular cholesterol accumulation and modulated aortic expression of the cholesterol transporter adenosine triphosphate-binding cassette transporter G1 and SRs CD36 and SR-A, thereby reducing atherosclerotic lesion burden in mice and humans[26]. Furthermore, Hong et al[26] showed that TMS activates the ERK/nuclear factor erythroid 2-related factor 2/heme oxygenase-1 signaling pathway in macrophages, resulting in enhanced lipid efflux. In summary, TMS substantially decreased the number of macrophage-derived foam cells in ApoE knockout mice and thereby reduced atherosclerosis[26].

Li et al[27] highlighted the role of RES in improving endothelial dysfunction. They showed that RES enhances eNOS expression by increasing intracellular cyclic adenosine monophosphate levels, which activate protein kinase A. This activation upregulates cyclic adenosine monophosphate-response element binding protein phosphorylation to promote cyclic adenosine monophosphate-response element binding protein DNA binding which in turn increases eNOS transcription in human aortic endothelial cells. Furthermore, RES treatment of human aortic endothelial cells decreased oxLDL-induced oxidative stress and preserved eNOS activity, leading to increased nitric oxide bioavailability[27]. Additionally, Li et al[27] demonstrated that RES treatment increased eNOS expression and cyclic guanosine monphosphate levels, markedly improving endothelial function and significantly reducing atherosclerotic lesion formation in hyperlipidemic ApoE-/- mice.

Nox proteins function as catalytic subunits of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, which has several isoforms in the body, including NADPH oxidase 2 (gp91phox) and p22phox[28]. NADPH oxidases 2 (Nox2)-driven reactive oxygen species (ROS) generation has been implicated in vascular oxidative stress; for example, glycated proteins can increase ROS via Nox2-dependent mechanisms[29], and chemokine signaling such as chemokine ligand 8 has been linked to Nox2/ROS-mediated increases in endothelial permeability[30]. Lixia et al[31] examined the role of NADPH oxidase in the development of atherosclerosis in VSMCs. RES has been shown to act on NADPH oxidase subunits in VSMCs by significantly decreasing gp91phox and p22phox gene expression[31]. Consequently, RES may reduce free radical formation in VSMCs, lower blood pressure and circulating lipids, and thereby decrease the risk of atherosclerosis[31].

Shi et al[32] used the oxidized phospholipid 1-palmitoyl-2-oxovaleroyl-sn-glycero-3-phosphorylcholine (POVPC) to induce VSMC proliferation and assessed the effects of RES on this process. POVPC markedly increased the proportion of VSMCs in the S phase while decreasing the proportion in the G0/G1 phase of the cell cycle. This finding indicates that POVPC enhances DNA synthesis in VSMCs and promotes their proliferation[32]. However, RES treatment counteracted these effects, indicating its role in suppressing POVPC-induced cell cycle progression. Specifically, RES inhibited DNA synthesis, preventing VSMCs from transitioning from the G1 to the S phase. Shi et al[32] also demonstrated that Cx43 contributes to VSMC proliferation and atherosclerosis. Cx43 is the principal gap junction protein in VSMCs and plays a key role in the development of atherosclerosis. Previous studies proved that Cx43 expression was significantly enhanced in VSMCs during early atherosclerosis development[33,34]. POVPC’s effect on Cx43 in VSMCs increased phosphorylation of Cx43 without affecting the expression of Cx43, suggesting that Cx43 phosphorylation may induce VSMC proliferation[33]. Treatment with RES suppressed POVPC induced phosphorylation of Cx43[33].

PHACTR1 is a gene associated with vascular diseases such as coronary artery diseases and carotid artery dissections. Analysis of the Gene Expression Omnibus database showed increased PHACTR1 expression in ruptured carotid arteries, suggesting a role in atherosclerosis development[35]. Previous studies demonstrated that PHACTR1 overexpression promotes endothelial inflammation and monocyte adhesion, thereby contributing to atherosclerosis[36]. Su et al[37] showed that RES substantially suppresses PHACTR1 gene and protein expression. According to their study, RES reduced tumor necrosis factor-alpha induced adhesion of human leukemic cell line monocytes to endothelial cells, but PHACTR1 overexpression reversed this effect, promoting adhesion. Thus, RES may protect against endothelial dysfunction by downregulating PHACTR1 expression and limiting monocyte adhesion and atherosclerosis[37].

As previously mentioned, atherosclerosis is characterized by thickening of the intima due to accumulation of macrophages. This occurs through the release of pro-inflammatory cytokines, MMPs, and reactive oxygen species. Macrophages promote atherosclerosis formation via accelerating inflammatory cell recruitment, VSMC migration, extracellular matrix deposition, and formation of thrombus[38]. Hence, atherosclerosis is highly dependent on the rate of monocyte recruitment and their differentiation into macrophages within the arterial wall. Phorbol myristate acetate induces monocyte-to-macrophage differentiation and promotes inflammation by upregulating intracellular glutathione via adenosine monophosphate-activated protein kinase activation, which in turn increases IL-1β, tumor necrosis factor-alpha, and monocyte chemoattractant protein-1 levels. Vasamsetti et al[39] showed that RES counteracts phorbol myristate acetate -induced monocyte-to-macrophage differentiation and consequently reduces inflammatory marker expression.

IL-18 is a proinflammatory cytokine that enhances the inflammation cascade by inducing the expression of proinflammatory cytokines, chemokines, and adhesion molecules[40]. IL-18 has been shown to accumulate in atherosclerotic lesions[41]. Moreover, elevated IL-18 levels have been reported to predict future cardiovascular events[42]. Extracellular MMP inducer (EMMPRIN) stimulates extracellular matrix degradation and facilitates cell migration, thereby increasing the risk of atherosclerosis. Venkatesan et al[43] demonstrated that IL-18 and EMMPRIN influence each other’s expression in smooth muscle cells through phosphatidylinositol 3-kinase, protein kinase B, and ERK-dependent signaling pathways. They demonstrated that RES inhibits IL-18-mediated oxidative stress, prevents IL-18- and EMMPRIN-dependent activation of phosphatidylinositol 3-kinase, protein kinase B, and ERK, blocks IL-18/EMMPRIN cross-regulation, and ultimately suppresses smooth muscle cells migration[43].

In this review, the unconventional mechanisms of RES can be integrated into four major mechanistic axes (Figure 1): (1) Modulation of gut microbiota and lipid-BA metabolism, particularly through reductions in TMAO; (2) Preservation of endothelial barrier integrity and nitric oxide bioavailability; (3) Inhibition of maladaptive vascular remodeling driven by smooth muscle cell activation and matrix degradation; and (4) Attenuation of immune and foam cell-mediated inflammation. Viewing these data through a network-based lens emphasizes that RES does not behave as a single-target antioxidant, but rather as a multi-target systems modulator along the atherosclerotic cascade.

Figure 1 Simplified network of unconventional mechanisms by which resveratrol attenuates atherosclerosis. Resveratrol (RES) acts as a multi-target modulator along four major mechanistic axes: (1) Gut microbiota and metabolism, where RES lowers trimethylamine N-oxide and improves bile acid-cholesterol homeostasis; (2) Endothelial function, where RES preserves aryl hydrocarbon receptor/sarcoma-dependent endothelial barrier integrity and enhances endothelial nitric oxide synthase-derived nitric oxide bioavailability; (3) Vascular wall remodeling, where RES inhibits transforming growth factor-β/extracellular regulated protein kinases-driven smooth muscle cell activation, matrix degradation, and plaque destabilization; and (4) Immune and foam cell responses, where RES reduces macrophage foam cell formation, inflammatory cytokine signaling, and monocyte recruitment. Together, these coordinated effects converge to limit atherosclerotic plaque progression and may ultimately reduce cardiovascular risk. RES: Resveratrol; TMAO: Trimethylamine-N-oxide; AHR/Src/VE: Aryl hydrocarbon receptor/sarcoma/vascular endothelial; eNOS: Endothelial nitric oxide synthase; NO: Nitric oxide; TGF-β/ERK: Transforming growth factor-β/extracellular regulated protein kinases; VSMC: Vascular smooth muscle cell.

These axes are not independent. Gut microbiota-derived metabolites such as TMAO influence endothelial function, inflammatory tone, and lipid handling; oxidative stress amplifies TGF-β/ERK signaling and foam cell formation; and endothelial gene programs (for example PHACTR1) sit at the interface of hemodynamic, metabolic, and inflammatory cues. Taken together, they form an interconnected mechanism network that RES can “rebalance” at multiple levels. Among these mechanisms, the most mature evidence derives from preclinical models of endothelial dysfunction, oxidative stress, and gut microbiota-TMAO signaling, supported by converging in vitro, animal, and early human data. By contrast, targets such as PHACTR1 regulation, Cx43-dependent smooth muscle proliferation, or IL-18/EMMPRIN crosstalk remain at an exploratory stage and require replication and translational validation. Distinguishing between well-established and emerging pathways may help prioritize which axes are most suitable for biomarker development and for incorporation into future RES-based clinical trial designs.

CONCLUSION

A growing body of experimental evidence indicates that RES acts as a multi-target modulator along several unconventional axes relevant to atherosclerosis, including gut microbiota-derived metabolites, endothelial barrier integrity and nitric oxide signaling, VSMC activation and matrix remodeling, and immune- and foam cell-mediated inflammation. Taken together, these data support the view that RES does not function as a simple antioxidant, but rather reshapes a broader mechanism network that collectively counteracts plaque initiation, progression, and destabilization.

However, translating these mechanistic insights into effective therapies remains challenging. A central obstacle is the poor oral bioavailability of RES, driven by rapid metabolism and low systemic exposure, which may limit the achievable pharmacological effects at clinically acceptable doses. This has prompted the development of novel formulations (such as nanoparticle-based systems, liposomal carriers, and sustained-release preparations) and structural derivatives designed to enhance stability, tissue penetration, and target engagement. Rigorous comparative studies are needed to determine whether these strategies meaningfully improve vascular outcomes beyond native RES.

Future clinical research should be explicitly informed by the mechanistic axes highlighted in this review. Trials will need to incorporate mechanism-based biomarkers - such as TMAO and BA profiles, markers of endothelial function and oxidative stress, and indices of vascular inflammation and plaque stability - and should seek to identify patient subgroups most likely to benefit, for example individuals with high residual inflammatory or metabolic risk. Carefully designed, adequately powered studies with clinically relevant endpoints are essential to bridge the current gap between promising preclinical data and routine cardiovascular prevention. By aligning formulation science, biomarker development, and patient stratification with the emerging mechanism network of RES, the field may ultimately determine whether these unconventional pathways can be harnessed to deliver tangible benefits in atherosclerotic cardiovascular disease.