Linking Heat Stress to Impaired Cardiac Repair: The ER Stress–Angiogenesis Axis as a Critical Barrier

Climate change has transformed extreme heat from a transient environmental perturbation into a persistent threat that worsens cardiovascular outcomes. Epidemiological studies show a lag between heat exposure and peaks in acute myocardial infarction (AMI) mortality, indicating a subclinical, latent vulnerability. This latent vulnerability likely originates at the level of the microvasculature, as cardiac microvascular endothelial cells (CMECs)—the heart’s primary “thermal sensors”—are uniquely susceptible to proteotoxic stress. The existing literature suggests that this sensitivity may be mediated by thermodynamically gated activation of the activating transcription factor 6 (ATF6) branch of the unfolded protein response (UPR), which could function as a master switch that reprograms endothelial cells from a pro-repair to a maladaptive, anti-angiogenic phenotype. However, this mechanism is derived primarily from preclinical studies and lacks direct validation in humans. The resulting “endothelial memory” is sustained by epigenetic modifications and organelle uncoupling; it persists beyond the initial insult and impairs subsequent neovascularization. As a result, ischemia occurs later in a compromised microenvironment, promoting a fibrosis–conduction mismatch that drives infarct expansion and arrhythmic risk. Thus, the post-exposure latent phase emerges as a novel therapeutic window: Precision targeting of the ER stress–angiogenesis axis during this period offers a focused strategy to protect heat-vulnerable individuals