Vitamin K2 Limits Ferroptosis-Associated Lipid Peroxidation and Attenuates Aortic Valve Stenosis

Background

Calcific aortic valve stenosis (AS) is the most common valvular heart disease in the aging population and lacks effective pharmacological therapy. Oxidative stress is a key feature of valvular remodeling, yet the mechanisms linking oxidative injury to calcification remain unclear. Ferroptosis, a lipid peroxidation-driven form of regulated cell death, has emerged as a key mediator of oxidative tissue injury and may contribute to cardiovascular disease. Vitamin K was recently identified as a suppressor of ferroptosis and cardiovascular calcification, but whether ferroptosis links vitamin K status to disease progression in AS remains unknown.

Methods and Results

We investigated the role of lipid peroxidation and ferroptosis in AS and their modulation by vitamin K2 using a translational approach. In human stenotic aortic valves, lipid peroxidation was markedly increased and localized to calcified regions, consistent with a ferroptosis-associated microenvironment. In primary human valvular interstitial cells (VICs), pro-calcific conditions induced lipid peroxidation and a pro-ferroptotic state. Pharmacological induction of ferroptosis enhanced VIC calcification, whereas its inhibition attenuated mineralization, supporting a causal role in osteogenic remodeling. Impaired vitamin K status was associated with increased valvular lipid peroxidation in AS patients. Conversely, vitamin K2 attenuated lipid peroxidation, preserved cell viability under ferroptotic stress, and partially normalized pro-ferroptotic and inflammatory transcriptional programs in VICs. In a murine model of AS, dietary vitamin K2 supplementation attenuated disease progression, reduced transvalvular gradients, and decreased valvular inflammation and lipid peroxidation-associated pathways. Finally, in a prospective cohort of patients with aortic sclerosis to moderate AS (n = 157), circulating undercarboxylated osteocalcin, a marker of impaired vitamin K status, was independently associated with accelerated disease progression.

Conclusions

Vitamin K2 counteracts ferroptosis-associated lipid peroxidation in AS and attenuates disease severity in vivo. Impaired vitamin K status is independently associated with accelerated progression in patients. These findings position vitamin K2 as a potential disease-modifying strategy and vitamin K status as a prognostic marker in AS.

What Is New?

• Ferroptotic lipid peroxidation is enriched in calcified regions of human stenotic aortic valves. Pharmacological induction of ferroptosis increases, and its inhibition reduces, calcification of human valvular interstitial cells, indicating a causal contribution to valvular mineralization.

• Vitamin K2 suppresses ferroptotic lipid peroxidation, preserves cell viability under ferroptotic stress, and shifts pro-oxidative and pro-inflammatory transcriptional programs in human valvular interstitial cells toward a protective state.

• In an in vivo model of aortic stenosis, dietary vitamin K2 attenuated hemodynamic progression, with lower peak transvalvular velocity and mean gradient, and reduced valvular inflammation and lipid peroxidation, without affecting coagulation

• In a prospective cohort of 157 patients with aortic sclerosis to moderate stenosis, impaired vitamin K status, reflected by higher circulating undercarboxylated osteocalcin, was independently associated with accelerated disease progression and with higher rates of mortality.

What Are the Clinical Implications?

• Aortic stenosis currently has no medical therapy. Vitamin K2, an inexpensive, safe nutrient that does not interfere with anticoagulation, emerges as a candidate disease-modifying strategy that warrants testing in randomized trials.

• Circulating undercarboxylated osteocalcin may serve as a biomarker to identify patients at risk of rapid progression and to enrich future vitamin K trials for those most likely to benefit.

• Targeting valvular lipid peroxidation, through antioxidant repletion and/or inhibition of lipid-peroxidation enzymes, may be a mechanistically grounded approach to slow calcific aortic valve disease.