When the body is exposed to extreme heat, thermal stress can directly cause irreversible damage to cells and tissues (31). Hyperthermia directly disrupts delicate cellular structures, leading to denaturation of critical proteins, inactivation of enzyme systems, altered fluidity and impaired integrity of cell membranes and mitochondrial dysfunction (32,33). This direct thermal injury effect is non-specific and can affect all cells in the body; however, vascular endothelial cells are considered an early and critical target of heat stress injury (34). Damage and dysfunction of endothelial cells compromise vascular barrier integrity, resulting in vascular leakage, tissue edema and triggering subsequent coagulation abnormalities and an inflammatory cascade (35,36).

At the molecular level, heat stress-induced mitochondrial dysfunction leads to excessive production of reactive oxygen species (ROS), which further oxidatively modify proteins, lipids and nucleic acids, exacerbating cellular damage (37,38). Concurrently, although the upregulation of heat shock protein (HSP) expression offers some protective effects, under sustained hyperthermia, these protective mechanisms are overwhelmed, failing to prevent cell death (39-41).

Building upon direct heat injury, the body initiates a potent immune and inflammatory response (42). Damaged cells and tissues release large quantities of damage-associated molecular patterns (DAMPs), such as high mobility group box 1 (HMGB1) (43). These DAMPs initiate innate immune responses by activating pattern recognition receptors such as Toll-like receptor 4 (TLR4). Activated immune cells (such as monocytes/macrophages and neutrophils) produce and release a tsunami of pro-inflammatory cytokines (such as TNF-α, IL-1β and IL-6), creating a 'cytokine storm' that further exacerbates tissue damage and organ failure (44).

The cytokine storm not only amplifies local inflammation but also affects distant organs via the circulatory system, leading to SIRS, characterized by fever, tachycardia, tachypnea and significant changes in white blood cell count. Simultaneously, heat stress activates multiple programmed cell death pathways, including apoptosis, necrosis, pyroptosis and the recently proposed PANoptosis (an inflammatory cell death program involving pyroptosis, apoptosis and necrosis concurrently) (20,45-49). These modes of cell death further release DAMPs, forming a positive feedback loop that continuously drives the inflammatory response and organ injury (50).

Heatstroke is often accompanied by a severe imbalance in the coagulation-anticoagulation systems. Endothelial damage exposes subendothelial collagen and tissue factor, activating the extrinsic coagulation pathway (10). Concurrently, inflammatory cytokines (such as TNF-α and IL-6) induce the expression of tissue factor on monocytes and endothelial cells, further initiating the coagulation cascade (51). Clinical and experimental studies both indicate that heatstroke patients exhibit thrombocytopenia, prolonged coagulation times, and elevated D-dimer levels, consistent with the features of DIC (52,53).

Endothelial dysfunction plays a central role in this process. Direct heat stress injury to endothelial cells leads to abnormal vasodilation, microthrombus formation and inadequate tissue perfusion, consequently causing ischemic and hypoxic injury (54-56). Disruption in nitric oxide (NO) metabolism, characterized by insufficient NO production leading to excessive vasoconstriction in the early stage, and overactivation of inducible nitric oxide synthase (iNOS) leading to persistent vasodilation and hypotension in the later stage, further exacerbates circulatory failure (57-60).

Notably, endothelial cells are uniquely vulnerable to ferroptosis. Their plasma membranes are enriched in PUFA due to high fluidity requirements and they are directly exposed to circulating free iron and heme released during rhabdomyolysis and hemolysis (19,61,62). Heat stress disrupts endothelial GPX4 expression and System Xc-activity, leading to uncontrolled lipid peroxidation. Ferroptotic endothelial cells lose barrier integrity, triggering microthrombus formation and DIC, thereby creating a vicious cycle in which endothelial ferroptosis amplifies the systemic inflammatory response (63-65). This mechanistic bridge positions endothelial ferroptosis as a central driver of multi-organ dysfunction in heatstroke.

The aforementioned pathological processes interact collectively, ultimately leading to MODS. The liver is one of the organs vulnerable in heatstroke; hyperthermia and ischemia-reperfusion (I/R) injury lead to hepatocyte necrosis, sharply elevated transaminases and synthetic failure (66). The kidneys suffer acute kidney injury due to reduced renal blood flow, direct heat toxicity and hemoglobinuria (secondary to rhabdomyolysis) (67). The central nervous system manifests cerebral edema, blood-brain barrier disruption and neuroinflammation, often resulting in consciousness impairment, seizures, or even coma (28). Impaired intestinal barrier function allows for gut microbiota translocation; endotoxin [lipopolysaccharide (LPS)] entering the circulation further stimulates systemic inflammation and coagulation responses, constituting a 'second hit' (68).

In summary, the pathophysiological mechanism of heatstroke is a vicious cycle initiated by direct heat toxicity, formed through the interplay of an inflammatory storm, coagulation activation, endothelial injury and various cell death pathways. Understanding this complex network is crucial for developing targeted early interventions to block disease progression. In this process, cell death plays a pivotal role. Historically, apoptosis and necrosis have been considered the primary forms of cell death in heatstroke. Studies have shown that moderate heat stress (such as 43-45°C) can activate intrinsic or extrinsic apoptotic pathways, such as the Ca²⁺-mediated mitochondrial apoptosis pathway or p53-dependent pathways, leading to orderly, programmed cell death. By contrast, extreme hyperthermia (such as >49°C) can rapidly induce cell membrane rupture and release of intracellular contents, resulting in typical necrosis and triggering a more intense inflammatory response. However, apoptosis and necrosis alone cannot fully explain the fulminant and progressive nature of organ damage observed in heatstroke. This gap in understanding has prompted researchers to explore the roles of other forms of programmed cell death, bringing ferroptosis into focus under such investigative context. A schematic diagram of the simple mechanism is shown in Fig. 1 and these pathological mechanisms are summarized in Table I.

The microenvironment for ferroptosis initiation in heat stress is constituted by a 'triple-hit' combination of oxidative stress burst, dysregulated iron metabolism and uncontrolled inflammatory response (74). Recent systematic explorations based on EHS animal models have revealed key molecular axes connecting heat stress signals to ferroptosis execution pathways (19,75,76). These mechanisms not only deepen the understanding of heatstroke pathophysiology but also indicate directions for developing precise therapeutic strategies.

Research into the molecular mechanisms of EHS-induced rhabdomyolysis has achieved a breakthrough (77). A study, utilizing single-cell sequencing and transcriptomic analysis, first demonstrated in an EHS mouse model that heat stress specifically activates YAP, a key effector of the Hippo signaling pathway (78). Activated YAP translocates to the nucleus and forms a transcriptional complex with transcription factors TEAD1/TEAD4, collectively upregulating the expression of ACSL4 (77,79). ACSL4 is a key executor of ferroptosis; it catalyzes the conversion of long-chain polyunsaturated fatty acids (PUFAs, especially arachidonic acid and adrenic acid) into their corresponding acyl-CoA esters, which are subsequently incorporated into membrane phospholipids, becoming preferred substrates for lipid peroxidation (80-82). The study further confirmed through gene knockout and pharmacological inhibition experiments that ACSL4 deficiency markedly alleviated ferroptosis in the skeletal muscle of EHS mice, reduced plasma myoglobin levels, and improved renal injury, thereby delineating a complete signaling chain at the molecular level: 'Heat stress → Hippo-YAP activation → ACSL4 upregulation → lipid remodeling → ferroptosis outburst' (77,83). Notably, this signaling axis does not exist in isolation; subsequent research revealed that YAP transcriptional activity is also directly regulated by heat shock factor 1 (HSF1), forming complex feedback loops (84).

The heat shock response (HSR) is a core endogenous protective mechanism for cells coping with environmental stresses such as high temperature (85). Its key regulator, HSF1, exerts chaperone functions by inducing the expression of the HSP family to maintain proteostasis (85-87). However, a complex 'bidirectional dialogue' and 'time-dependent switch' relationship exists between the HSR system and ferroptosis. On one hand, specific HSP members have been identified as negative regulators of ferroptosis (88). For instance, the phosphorylated form of heat shock protein B1 (HSPB1, also known as HSP27) can directly antagonize ferroptosis by stabilizing the actin cytoskeleton and inhibiting iron influx. HSP90 is considered a common regulatory node connecting ferroptosis and necroptosis and its inhibitors can promote ferroptosis execution (89). On the other hand, when the intensity or duration of heat stress exceeds the compensatory capacity of the HSR, HSF1 may trans-activate pro-ferroptotic genes, forming a 'protection-to-damage' switch (90). A study revealed the paradoxical role of HSP70 in EHS: Early upregulation of HSP70 inhibits lipid peroxidation by enhancing GPX4 stability, but sustained heat stress leads to HSP70 overexpression, which interacts with iron-responsive element-binding protein 2, however, promoting the expression of the iron uptake protein transferrin receptor 1 (TFR1), exacerbating iron overload and ferroptosis (91-93). This 'HSR paradox' phenomenon suggests that the timing and intensity of intervention are crucial determinants of therapeutic success (94).

The transition from HSP70-mediated protection to HSF1-driven pro-ferroptotic signaling is not a binary switch but a dose-dependent and time-dependent continuum. At moderate thermal stress (≤42°C) and early time points (<6 h), HSP70 functions as a chaperone stabilizing GPX4 and HSF1, thereby protecting against ferroptosis. At severe thermal stress (>43°C) or prolonged exposure (>12 h), the HSR system becomes overwhelmed, HSF1 translocates to the nucleus and upregulates TFR1 expression via direct promoter binding and HSP70 dissociates from GPX4. The severity of the thermal dose determines the relative balance between HSP70-GPX4 binding (protective) and HSF1-TFR1 activation (pro-ferroptotic). Under intermediate stress conditions, HSP70 can simultaneously exert both roles in different cellular compartments, reflecting the complexity of the heat shock response (95-98).

Nrf2 is the most critical transcription factor for intracellular antioxidant stress responses (99). Under basal conditions, Nrf2 is anchored in the cytoplasm by Keap1 and subjected to continuous degradation (100). Under the severe oxidative stress caused by heatstroke, activation of the Nrf2 pathway should initiate the transcription of a series of protective genes, including GPX4, SLC7A11 (a subunit of the cystine/glutamate antiporter xCT), and heme oxygenase-1 (HO-1) (73,101-103). However, there is a dual dysfunction of 'suppression-exhaustion' in the Nrf2 pathway in EHS patients and animal models (104). In the acute phase, overactivated p53 inhibits SLC7A11 expression, severing the cystine uptake-GSH synthesis pathway, leading to GPX4 inactivation due to cofactor depletion (21,77,105,106). Concurrently, high concentrations of TNF-α in the inflammatory microenvironment can activate the NF-κB pathway, inducing the expression of the Nrf2 inhibitory protein Keap1, forming a cascading inhibitory effect (107-113). More critically, a series of studies revealed a parallel defense axis, GPX4-independent ferroptosis defense axis; the FSP1-CoQ10-NAD(P)H system (77,104,114-116). FSP1 utilizes its NAD(P)H-dependent reductase activity to reduce CoQ10 to the antioxidant form ubiquinol (CoQ10H2), which directly scavenges lipid peroxyl radicals (75,115). In EHS models, FSP1 expression in skeletal muscle and liver tissues shows a dynamic 'rise-then-fall' pattern: Early upregulation represents a cellular compensatory response, but sustained heat stress leads to increased methylation in the FSP1 promoter region, suppressing its transcription and ultimately causing the failure of both the GPX4 and FSP1 systems, resulting in an irreversible outburst of ferroptosis (22,117,118). Additionally, dihydroorotate dehydrogenase, localized to mitochondria, has also been confirmed as an endogenous inhibitor of ferroptosis. By competitively utilizing CoQ10, it forms a mitochondrial-cytosolic collaborative defense network with FSP1 (119).

Based on current evidence, System Xc-failure (SLC7A11/GSH depletion) is considered the primary driver of ferroptosis in heatstroke, while FSP1/CoQ10 failure acts as a secondary, compensatory pathway that becomes critical when GPX4 is already compromised. System Xc-is the dominant antioxidant defense because heat stress directly inhibits cystine uptake and glutamate efflux, leading to rapid GSH depletion. FSP1/CoQ10 provides a parallel pathway that can partially compensate for GPX4 loss, but it is insufficient alone to prevent ferroptosis when System Xc-is severely impaired. Lethal injury typically requires failure of both pathways, but System Xc-failure is the earlier and more decisive event. This hierarchical model of defense collapse is supported by the observation that DFO and Fer-1 (which target the iron-peroxidation axis) are more effective than Nrf2 activators alone in heatstroke models (11,115,120).

Systemic iron metabolism dysregulation induced by heatstroke is a key driver for the continuous amplification of ferroptosis. A study found that serum ferritin levels in EHS patients are markedly positively associated with disease severity (APACHE II score) and the number of organ failures (121). This elevation is not merely an acute phase response but rather a consequence of increased iron release caused by ferroptosis-associated ROS activating ferritinophagy (22). Ferritin heavy chain 1 is selectively degraded via autophagy mediated by NCOA4 under heat stress, releasing large amounts of free Fe²⁺ (122,123). This Fe²⁺ catalyzes the generation of ·OH via the Fenton reaction, further exacerbating lipid peroxidation (124). Simultaneously, imbalance in the hepcidin-ferroportin (FPN) axis leads to iron retention within parenchymal cells (hepatocytes, renal tubular epithelial cells), creating an 'iron trap' microenvironment (125,126). A preclinical study using FPN conditional knockout mice confirmed that deletion of FPN in intestinal epithelial cells worsened EHS-related intestinal barrier injury and increased bacterial translocation, whereas intervention with DFO reversed this process and markedly reduced the incidence of multiple organ failure (77,126,127). This reveals the central role of the 'iron overload-ferroptosis-organ injury-systemic inflammation' vicious cycle in heatstroke progression.

Heatstroke pathology is multi-modal and ferroptosis does not operate in isolation. Multiple cell death modalities may coexist in the same tissue, with ferroptosis dominating in iron-rich tissues (kidney and liver) and pyroptosis or necroptosis more prominent in immune cells (19,73). The present study highlighted four cross-talk nodes, distinguished by evidence strength:

i) Ferroptosis-pyroptosis axis (best supported): Ferroptotic cells release lipid peroxidation products (such as oxidized phospholipids) that act as DAMPs, activating the NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3) inflammasome and triggering pyroptosis in neighboring macrophages (128,129). Conversely, IL-1β and IL-18 released during pyroptosis can further deplete GSH and exacerbate ferroptosis, creating a bidirectional amplification loop (130,131). This cross-talk is supported by evidence in heatstroke models (such as cGAS-STING-NLRP3 pathway activation) (132).

ii) Ferroptosis-endothelial injury axis (emerging evidence): Endothelial cells are uniquely vulnerable to ferroptosis due to their PUFA-rich plasma membranes and direct exposure to circulating free iron (19). Ferroptotic endothelial injury exposes subendothelial tissue factor, disrupts tight junctions, and promotes barrier dysfunction (19), thereby fueling the coagulation cascade. Conversely, endothelial damage-driven ischemia and ROS generation create a microenvironment that further sensitizes endothelial cells to ferroptosis.

iii) Ferroptosis-coagulation axis (plausible but under-investigated): DIC and microthrombosis generate regional ischemia-hypoxia, which exacerbates ferroptosis through ROS accumulation and iron-mediated Fenton chemistry. In turn, ferroptosis-derived oxidized phospholipids can activate platelets and propagate coagulation cascade signaling (133), forming a vicious cycle. Direct experimental validation in heatstroke models remains limited.

iv) Ferroptosis-necroptosis axis (largely theoretical): Potential interactions via RIPK3-ROS signaling or MLKL pore-mediated ion influx have been proposed in other disease contexts (134), but specific evidence in heatstroke is currently lacking.

This multi-modal interplay underscores that heatstroke is not a single-mechanism disease and that therapeutic strategies must address multiple injury pathways simultaneously. These pathological mechanisms are summarized in Table II.

Ferroptosis is an iron-dependent, lipid peroxidation-driven form of regulated cell death. It is not confined to a single organ during the course of heatstroke but is extensively involved in the pathological process of multiple organ injury. The mechanisms and evidence of ferroptosis in major organ damage induced by heatstroke are systematically elaborated below and shown in Fig. 2.

Exertional heatstroke is frequently accompanied by rhabdomyolysis (RM), which is a typical manifestation of ferroptosis. Evidence primarily derives from EHS models, given that rhabdomyolysis is a hallmark of EHS. Generalization to classical heat stroke (CHS) should be made with caution. Studies have confirmed that ACSL4 expression is upregulated in skeletal muscle following EHS. By promoting the incorporation of polyunsaturated fatty acids into membrane phospholipids and driving lipid peroxidation, ACSL4 directly leads to ferroptosis in muscle cells. ACSL4-mediated ferroptosis causes rupture of the myocyte membrane, releasing large amounts of myoglobin, potassium ions, and creatine kinase (CK). This not only results in local muscle tissue necrosis, disordered fiber arrangement, and edema, but these released substances entering the circulation can also induce secondary damage such as acute kidney injury (AKI) (77,135-138). In animal models, using ACSL4 inhibitors (such as Rosiglitazone) or the ferroptosis inhibitor Fer-1 markedly alleviated EHS-induced rhabdomyolysis, reduced serum CK and myoglobin levels, and improved muscle function (19). The dominant trigger is ACSL4 upregulation driven by Hippo-YAP activation, which promotes PUFA-phospholipid peroxidation and leads to rhabdomyolysis. Secondary mechanisms, including HSP70 chaperone failure and Nrf2 antioxidant collapse, further amplify ferroptotic damage but are summarized here as contributory rather than primary drivers.

Through single-cell transcriptomic analysis of peripheral blood mononuclear cells from heatstroke patients, researchers have screened potential diagnostic marker genes related to ferroptosis, such as ACSL1, MAPK14, ALOX5AP, PROK2 and DUSP1 (156). Measuring the mRNA levels of these genes or their encoded proteins in blood may reflect the activity of ferroptosis in vivo. Furthermore, assessing changes in the levels of core proteins such as GPX4 and ACSL4 in blood also holds potential value (157,158). In severe COVID-19 patients, decreased GPX4 is closely associated with ferroptosis activation, suggesting it might similarly serve as an important indicator under analogous oxidative stress conditions in heatstroke (158).

Malondialdehyde (MDA) and 4-hydroxynonenal (4-HNE) are end products of lipid peroxidation and their levels directly reflect the execution degree of ferroptosis (159,160). In critical illnesses such as sepsis and severe COVID-19, serum levels of MDA and 4-HNE are markedly elevated and positively correlate with APACHE II and SOFA scores (161-163). Although data from dynamic monitoring in heatstroke patients and its correlation with scoring systems are still lacking, detecting these products remains the most direct method for assessing the extent of oxidative stress and ferroptosis-related damage in heatstroke (164).

Heatstroke is often accompanied by disordered iron metabolism. Changes in indicators such as serum iron, ferritin and transferrin may indirectly reflect the risk of ferroptosis (165). In severe inflammatory states such as COVID-19 and sepsis, hyperferritinemia is closely associated with disease severity and poor prognosis (166,167). Experimental studies also show that in exertional heatstroke models, serum myoglobin promotes ferroptosis in renal tubular epithelial cells by upregulating p53 and inhibiting SLC7A11 and GPX4 expression, suggesting that myoglobin could also serve as a ferroptosis-related biomarker for assessing renal injury in heatstroke (19,77).

Studies have found that proteins such as sRAGE and GDF-15 are closely associated with ferroptosis and organ damage in severe infections and inflammatory states (168-170). Furthermore, exosome-carried ferroptosis-related molecules (such as lipid peroxides and iron metabolism proteins) transmit death signals between cells and might represent a new direction for liquid biopsy (171-173).

It is important to distinguish between upstream triggers of ferroptosis and specific ferroptosis biomarkers. Myoglobin, released during rhabdomyolysis, is a marker of muscle injury severity, not a specific ferroptosis biomarker. It promotes ferroptosis by releasing free iron and catalyzing lipid peroxidation in renal tubular cells, but it does not reflect the core execution mechanisms of ferroptosis. True ferroptosis biomarkers should reflect the execution machinery, such as MDA/4-HNE for lipid peroxidation, ACSL4 for PUFA incorporation, or GPX4 loss for antioxidant failure. In the context of heatstroke, myoglobin should be classified as an upstream trigger and risk factor; rather than a 'core ferroptosis biomarker' and caution should be exercised to avoid biomarker over-interpretation. These potential ferroptosis biomarkers in heatstroke are summarized in Table IV.

Current research on ferroptosis biomarkers for heatstroke is still in its infancy, with most evidence derived from other critical illness models such as sepsis and COVID-19 (174,175). Future work requires prospective dynamic monitoring in heatstroke clinical cohorts, correlating the aforementioned biomarkers with traditional scores (APACHE II and SOFA) and organ function outcomes, and utilizing methods such as machine learning to construct multi-biomarker predictive models (176). Simultaneously, intervention studies targeting key molecules in the ferroptosis pathway (such as GPX4, SLC7A11 and ACSL4) hold promise for providing new therapeutic strategies for heatstroke (156,177).

Ferroptosis-related readouts may provide incremental prognostic value beyond conventional markers (such as lactate, CRP, creatinine and transaminases) because they reflect the underlying mechanism of cell death rather than generic organ injury or inflammation. This mechanistic specificity could enable earlier intervention (before irreversible organ damage) and guide targeted therapy selection. The most plausible sampling window is 0-6 h post-cooling, during the peak of lipid peroxidation. Signal separation is most expected in patients with rhabdomyolysis (high iron load) or those with SOFA ≥4. A feasible validation approach would be a prospective cohort design with serial sampling (0, 6, 12 and 24 h) combined with machine learning models integrating ferroptosis markers (MDA, ACSL4 and GSH/GSSG) with SOFA/APACHE II scores to predict organ failure and mortality (178-182).

In summary, ferroptosis-related biomarkers (including core regulatory proteins, lipid peroxidation products and iron metabolism indicators) demonstrate significant potential value in assessing heatstroke severity. Through further clinical validation, these biomarkers are expected to enable early warning, severity stratification and prognosis prediction for heatstroke, providing essential tools for precision medicine.

Ferroptosis inhibitors are primarily categorized into three classes based on their targets. Iron chelators, such as DFO, function by chelating excess intracellular free iron, thereby blocking the initiation of iron-catalyzed Fenton reactions at the source and inhibiting lipid peroxidation. DFO has been shown to mitigate ferroptosis-related injury in models such as intracerebral hemorrhage and I/R, providing a rationale for its potential application in heatstroke (127,184). Lipid peroxidation inhibitors, including Fer-1 and Lip-1, directly scavenge lipid radicals to interrupt the chain reaction. They have demonstrated significant cytoprotective effects in heatstroke cardiomyocyte models and acute lung injury models, reducing lipid peroxidation products such as MDA and 4-HNE while restoring the expression of key proteins such as GPX4 and SLC7A11 (75,185). Another approach involves agents that restore GPX4 function, which enhances the cellular capacity to clear lipid peroxides by supplementing GSH precursors or directly activating GPX4 (104). Furthermore, SIRT1 agonists can inhibit heat stress-induced ferroptosis in lung epithelial cells by deacetylating p53 and subsequently upregulating GPX4 and SLC7A11 (75).

Therapeutic strategies targeting ferroptosis have achieved notable success in preclinical models. Fer-1 markedly alleviated rhabdomyolysis, reduced serum creatine kinase levels and improved survival rates in a mouse model of heatstroke (77). In heat stress-induced cardiomyocyte injury, Fer-1 effectively mitigated ferroptosis markers and protected cardiac function (133). Lip-1 also exhibited protective effects in a heatstroke-associated acute lung injury model, reducing inflammation and blocking ferroptosis via inhibition of the TLR4/NF-κB signaling pathway (133). The ACSL4 inhibitor Rosiglitazone alleviated muscle damage in an exertional heatstroke model by inhibiting ACSL4-mediated lipid remodeling (77). Additionally, novel approaches such as curcumin-loaded nanovesicles have shown promise by attenuating heatstroke-induced neuronal ferroptosis in the hypothalamus via upregulation of the PCBP2/SLC7A11 axis, leading to improved neurological outcomes and survival (186). These data robustly indicate that ferroptosis inhibitors possess broad-spectrum protective potential against multi-organ damage in heatstroke and are promising as effective adjuncts to traditional therapies. The corresponding therapeutic targets are shown in Fig. 3 and these therapeutic strategies are summarized in Table V.

Given the strong time-dependence of heatstroke management, ferroptosis-targeted interventions should be stratified by clinical timing and grouped into three tiers: i) Tier 1 (upstream stabilization, 0-1 h): Anti-inflammatory agents (such as Xuebijing) and endothelial stabilizers (such as epoprostenol) should be initiated during active cooling, with measurable endpoints including coagulation markers (D-dimer and PT/INR) and endothelial injury markers (sTM and sICAM-1); ii) Tier 2 (Iron/lipid radical blockade, 1-6 h): Iron chelators (DFO) and lipophilic antioxidants (Fer-1 and CoQ10) should be initiated during the post-cooling phase, with endpoints including serum ferritin, MDA/4-HNE and AKI incidence; iii) Tier 3 (mitochondrial/antioxidant restoration, 6-24 h): Nrf2 activators (such as sulforaphane) and mitochondrial protective agents (such as MitoQ) should be initiated during the recovery phase, with endpoints including lactate clearance, GSH/GSSG ratio and neurological outcomes (Glasgow Coma Scale) (10,187-192). This stratification aligns with the pathophysiological trajectory of heatstroke and emphasizes that the therapeutic window for ferroptosis inhibition is narrow and organ-specific.

However, translating ferroptosis inhibitors from the laboratory to the clinic still faces multiple challenges. Key issues include the poor in vivo stability and low bioavailability of compounds such as Fer-1 and Lip-1, which limit clinical application, although strategies such as nanocarrier encapsulation are being explored to enhance their delivery (193,194). Determining the optimal therapeutic time window is also critical, as most studies indicate administration must occur early after heat stress for best efficacy (75). Furthermore, the potential of combination therapies, such as using ferroptosis inhibitors alongside apoptosis inhibitors, warrants investigation in heatstroke models, given the coexistence of different cell death pathways (15). Advancing clinical translation requires validating efficacy and safety in large animal models, developing reliable biomarkers for monitoring ferroptosis in patients, and ultimately designing randomized controlled trials targeting severe heatstroke patients (73).

A critical translational hurdle is the near-exclusive reliance on prophylactic administration in the current literature. Most preclinical studies administer ferroptosis inhibitors prior to the thermal insult (Fer-1 30 min to 2 h before heat stress), which does not reflect clinical reality. To date, only one study has systematically evaluated post-insult efficacy: He et al (77) administered Fer-1 at 0, 6, and 12 h after EHS onset in mice. Fer-1 given immediately (0 h) or at 6 h post-insult markedly improved survival and attenuated rhabdomyolysis, whereas administration at 12 h showed limited survival benefit but still reduced muscle injury. These data confirm that a therapeutic window exists but narrows rapidly after the insult. By contrast, Luan et al (19) demonstrated ferroptosis involvement in myoglobin-induced renal tubular injury using an in vitro heat-stress model, but did not evaluate pharmacological interventions in vivo. The scarcity of post-insult in vivo efficacy data, particularly for iron chelators such as DFO, represents a massive translational hurdle. Without evidence that ferroptosis inhibitors are effective when administered after heat exposure, their clinical utility in emergency settings remains unproven. Combination with rapid cooling, which may itself attenuate ferroptosis by reducing ROS production, represents the most realistic near-term strategy.