Landscape of Berberine Targets: A Potential Pharmacological Insight for Heart Failure Treatment

Berberine, the primary active compound in Coptis chinensis Franch, is well known for its anti-infective, hypoglycemic, lipid-lowering, antitumor, and anti-inflammatory effects. This review summarizes the physicochemical and pharmacokinetic characteristics of berberine, its intraintestinal pharmacology involving gut microbiota cross-talk to heart failure (gut-cardiac axis), extraintestinal pharmacology in heart failure, and network pharmacology. Berberine enhances the intestinal barrier, reducing endotoxin entry into the bloodstream. It also regulates the intestinal flora composition, notably altering the Bacillota/Bacteroidota ratio. Importantly, berberine promotes beneficial bacteria while inhibiting pathogenic bacteria. In addition, it influences gut microbiota metabolites, decreasing trimethylamine and trimethylamine N-oxide while increasing short-chain fatty acids. Berberine addresses extraintestinal direct mechanisms by mitigating heart failure risk factors such as atherosclerosis, hyperglycemia, and hyperlipidemia. It also decreases cardiac oxygen consumption, oxidative stress, and endoplasmic reticulum stress, thereby reducing chronic cardiac inflammation, apoptosis, and remodeling, while enhancing myocardial energy to improve cardiac function. Network pharmacology analysis has identified the top 10 hub genes for berberine in heart failure therapy: STAT3, TNF, MTOR, NFKB1, HIF1A, ESR1, BCL2, PTGS2, PPARG, and MMP9. Notably, TNF, HIF1A, and PPARG are key targets for berberine in heart failure with preserved ejection fraction treatment. Berberine shows promise for heart failure treatment, but its bioavailability needs improvement. In addition, the efficacy and safety of berberine in clinical heart failure management, especially in heart failure with preserved ejection fraction, require further evaluation through large-scale, multicenter clinical trials.