Melatonin suppresses atherosclerosis by ferroptosis inhibition via activating NRF2 pathway

Abstract Melatonin (MLT), a conserved small indole compound, exhibits anti‐inflammatory and antioxidant properties, contributing to its cardioprotective effects. Lipoprotein‐associated phospholipase A2 (Lp‐PLA2) is associated with atherosclerosis disease risk, and is known as an atherosclerosis risk biomarker. This study aimed to investigate the impact of MLT on Lp‐PLA2 expression in the atherosclerotic process and explore the underlying mechanisms involved. In vivo, ApoE −/− mice were fed a high‐fat diet, with or without MLT administration, after which the plaque area and collagen content were assessed. Macrophages were pretreated with MLT combined with ox‐LDL, and the levels of ferroptosis‐related proteins, NRF2 activation, mitochondrial function, and oxidative stress were measured. MLT administration significantly attenuated atherosclerotic plaque progression, as evidenced by decreased plaque area and increased collagen. Compared with those in the high‐fat diet (HD) group, the levels of glutathione peroxidase 4 (GPX4) and SLC7A11 (xCT, a cystine/glutamate transporter) in atherosclerotic root macrophages were significantly increased in the MLT group. In vitro, MLT activated the nuclear factor‐E2‐related Factor 2 (NRF2)/SLC7A11/GPX4 signaling pathway, enhancing antioxidant capacity while reducing lipid peroxidation and suppressing Lp‐PLA2 expression in macrophages. Moreover, MLT reversed ox‐LDL‐induced ferroptosis, through the use of ferrostatin‐1 (a ferroptosis inhibitor) and/or erastin (a ferroptosis activator). Furthermore, the protective effects of MLT on Lp‐PLA2 expression, antioxidant capacity, lipid peroxidation, and ferroptosis were decreased in ML385 (a specific NRF2 inhibitor)‐treated macrophages and in AAV‐sh‐NRF2 treated ApoE −/− mice. MLT suppresses Lp‐PLA2 expression and atherosclerosis processes by inhibiting macrophage ferroptosis and partially activating the NRF2 pathway.