Focus on Herbs

HawthornThe Heart Helper

By David Hoffmann,B.Sc, M.N.I.M.H.

Frank, a 58-year-old patient youhave been treating for congestiveheart failure, comes into your office

one day to tell you about a discovery hehas made. Unable to contain his excite-ment for very long, he proudly pulls outof his pocket a bottle containing capsulesof the herb hawthorn. He tells you that heis taking it along with the regular medica-tion you have prescribed for his condi-tion. After explaining the usual cautionsabout self-medication for his condition,you begin to wonder whether thishawthorn might be doing him some

good—or potential harm.Not since the herb digitalis was intro-

duced have physicians and patients alikebeen giving an herb so much attention.Although digitalis offered therapeuticbenefits in the treatment of congestiveheart failure, it was not totally risk-free:Toxicity was evident, and there was also a

low therapeutic index. Clinicians, howev-er, can relax when it comes to hawthorn,because it is exceptionally safe.As an ever-increasing number of

patients is discovering the valuable thera-peutic properties of herbs, it is importantthat physicians keep well informed aboutthese important botanicals. Given the con-

tinued interest in hawthorn and its vari-ous cardiovascular effects, knowledgeabout this herb is critical, particularly forphysicians treating a fair number ofpatients with cardiac disorders.

Description and CompositionNative to Europe, hawthorn (Crataegus

oxyacantha) grows as a spiny tree or shrubwith thorny, branching stems. Actually,

almost 1,000 species of hawthorn havebeen described in the literature, althoughthe actual number is now considered tobe far less.1 In spring, hawthorn producesbeautiful white flowers, giving it theother popular name of whitethorn. Boththese blossoms and the berries they pro-duce are used for their therapeutic prop-erties.Before it was introduced to the North

American medical community in the 19thcentury, hawthorn already had a long his-tory of use in Europe. Even then, clini-cians were taking notice of its remarkablecardiovascular applications. One practi-tioner described hawthorn as "superior toany of the well known and tried remediesat present in use for the treatment of heartdisease, because it seems to cure, whileother remedies are only palliative atbest."2 Since that time, hawthorn hasbeen used as a folk remedy, primarily as a

cardiac tonic and a mild diuretic. Becauseof its astringent properties, it was evenused to treat sore throats.

PharmacologyHawthorn's therapeutic effect stems

from its flavonoid components and theproanthocyanidins, which are responsiblefor its cardiovascular activities. A numberof flavonoids have been identified,including hyperoside, rutin, quercetin,kaempferol, apigenin, and vitexin 4'-rhamnoside.3 Flavonoids and flavones are

commonly found in a variety of plants,usually grouped together and workingsynergistically. Some flavones, such as

those found in hawthorn, reduce capillarypermeability, possess hypotensive prop-erties, and regulate cardiovascular activi-ty.4 Since they also have a gentle and ben-eficial effect on a wide range of organsand physiologic processes within the

body, flavonoids and flavones are consid-ered biologic response modifiers.5

The important therapeutic properties ofhawthorn are most recognized andaccepted by clinicians in Europe. Suchacceptance has been fostered by theresults of a four-year study of hawthorncommissioned by the German FederalMinistry of Health. The study concludedthat hawthorn increases vascular contrac-tility, cardiac frequency, and the rate ofblood flow.6 Hawthorn was also found toincrease both coronary and myocardialcirculation by its dilation effect on thecoronary arteries. This monumental studyconcluded that the main clinical applica-tion of hawthorn is in the long-term treat-ment of low cardiac function or in any sit-uation in which the patient has subjectivefeelings of congestion and oppression inthe heart region. Results from the studyalso revealed hawthorn's role in the treat-ment of mild arrhythmias. Clinicianswere most relieved by the major revela-tion that hawthorn has no contraindica-tions or side effects when used in the clin-ical management of these patients.By dilating the coronary arteries,

hawthorn exhibits its observable effect ofimproving coronary circulation. Suchdilation of the coronary arteries results ina reduction in cardiac hypoxemia. Aftertaking hawthorn, patients report a reduc-tion in number of angina attacks, as wellas symptom relief. Flavonoids may exerttheir cardiotonic effect on the heart byinhibiting cellular phosphodiesterase andelevating the cellular concentration ofcAMP. Flavonoids also affect the perme-ability of cell organelles to calcium ions.Whereas digitalis and other cardiac glyco-sides, also found in plants, impact thecontractile fibers of the heart, hawthornhas a completely different mechanism ofaction: It is involved in the availability

191

192 ALTERNATIVE & COMPLEMENTARY THERAPIES—APRIUMAY 1995

Clinical Indications forHawthorn

Age-related reduced cardiac function thatdoes not require digitalis

Coronary artery disease (CAD)Congestive heart failure (CHF)Essential hypertensionAngina pectorisPostmyocardial infarction (Ml) rehabilita-

tion

Cardiac weakness following an infectiousdisease (e.g., diphtheria)

Dosage and Preparationof Hawthorn

As a pleasant-tasting tonic: Add 2 tspof dried hawthorn berries to I cupfreshly boiled water. Steep for 15 minand drink.As a component of treatment pro-grams: I tsp (5 ml) of hawthorn tinc-ture three times per day; OR 200 to300 mg of standardized extract intablet form three times per dayNo adjustments in dose or dosage areneeded in the elderly or children.

and utilization of energy.7 Such activityaccounts for the gentle yet long-termeffect achieved by hawthorn on degenera-tive, age-related changes in the myocardi-um. While hawthorn does not producerapid results, the results obtained remainpersistent once they are achieved.

Clinical Applications and Use

Hawthorn is used in the treatment ofatherosclerosis, hypertension, congestiveheart failure, and arrhythmias (see side-bar).8 In addition, hawthorn is frequentlyused as a preventive in older patientswhere no disease exists but a gradual lossof cardiac function is evident. The mainadvantages to using hawthorn are its lackof toxicity, accumulation, and habitua-tion. Patients can safely use hawthornover the long term while achieving thera-peutic goals safely and effectively.9 InGreat Britain, clinicians considerhawthorn specifically indicated in thetreatment of hypertension associated withmyocardial weakness.10 Practitionerswho use herbs in their practice includehawthorn in their prevention protocols

for long-term cardiovascular degenera-tion. Many British practitioners also con-

sider hawthorn essential in patientsrecovering from a recent myocardialinfarction. Some practitioners have even

found a use for hawthorn in the treatmentof varicose veins and thrombosis.With its unique ability to lower blood

pressure, hawthorn is used for its mildantihypertensive effect in patients withhypertension. In these patients, hawthorndilates coronary arteries, inhibitsangiotensin converting enzyme (ACE),acts as an inotropic agent, and confersmild diuretic activity. One small word ofcaution is in order for patients who takeß-blockers to lower their blood pressure.Since ß-blockers reduce cardiac output inthese patients, hawthorn may cause a

mild rise in their blood pressure.The combination of hawthorn and digi-

talis has had a long history of use in thetreatment of congestive heart failure.Hawthorn has been found to enhance theeffect of the cardiac glycosides found indigitalis. This is probably accomplishedby the inhibitory effect hawthorn has on

cAMP-PDE and its effect on calcium chan-nels. As such, when patients takehawthorn, the dose of digitalis can be low-ered. Patients with mild to moderate con-

gestive heart failure may benefit fromhawthorn by itself. For those patients withmoderate to severe congestive heart fail-ure, a combination of hawthorn with othercardiac glycosides should be employed.In addition to hawthorn's combined

use with digitalis, some practitioners use

it along with other medicinal plants.These include linden and garlic for thetreatment of atherosclerosis. Patients withhypertension often benefit from hawthornused in conjunction with cramp bark andlinden. Horse chestnut is often used withhawthorn to treat patients with varicoseveins.

Dosage Parameters

As with other herbs, the dosage ofhawthorn for use in patients depends on

the way it is prepared and the nature ofthe source herb (see sidebar). In Europeand Asia, standardized extracts are usedas prescription medications. Such extractscontain 1.8 percent vitexin 4'-rhamnosideor 10 percent procyanidins, with the usualdose being 120 to 240 mg three times perday.11 These are also available on a com-

mercial basis.The doses of hawthorn suggested are

usually taken by the patient three times

per day. An infusion of the dried fruitscan be taken in doses of 0.3 to 1 g. If a

fluid extract is used, the dose is 1 to 2 mlof a 1:1 liquid extract in 25 percent alco-hol. Tinctures are usually given in dosesof 2 to 4 ml of a 1:5 tincture in 45 percentalcohol.10 Although these recommendeddoses are standard, some patients can

take much higher doses, depending on

the indication.While hawthorn cannot be viewed as

an alternative to the more powerful car-diovascular agents available to today'sclinician, it does offer unique propertiesthat can complement the work of thesedrugs. As the gentle tonic that it is,hawthorn can be safely taken by patientsin conjunction with their other medica-tions. D

References1. Hortus Third. New York: Macmillan, 1976.2. Ellingwood, F. American Materia Medica,Therapeutics and Pharmacognosy (1898). Port-land, OR: Eclectic Medical Publications, 1983.3. Hobbs, C. Crataegus oxyacantha: A Monographand Literature Review. Austin, TX: AmericanBotanical Council.4. Wagner, H. Non-steroid, cardioactive plantconstituents. In: Wagner, Hikino, Farnsworth(eds.), Economic and Medicinal Plant Research.Vol. 2. San Diego: Academic Press, 1988.5. Blesken, R. Crataegus in cardiology. FortschrMed 110(15):290-292,1992.6. Monographie: Crataegus (weissdorn) 3.1(1),1984.7. Popping, et al. Effect of crataegus extract onthe contraction and the consumption of oxygenof isolated cardiac muscle cells. Med Wschr136:39^6,1994.8. Weiss, R. Herbal Medicine. Portland, OR:Medicina Biológica, 1988.9. O'Conolly, et al. Treatment of decreasingcardiac performance: Therapy using standard-ized crataegus extract in advanced age. FortschrMed 104(42):805-808,1986.10. British Herbal Pharmacopoeia. Bournemouth:British Herbal Medicine Association, 1990.11. Werbach, Murray. Botanical Influences on Ill-ness. Tarzana, CA: Third Line Press, 1994.

David Hoffmann, B.Sc, M.N.I.M.H., is a pro-fessor of integral health studies and director ofthe Herbal Studies Program, California Insti-tute of Integral Studies, San Francisco, Califor-nia.

To order reprints of this article, write to or call:Karen Ballen, ALTERNATIVE & COMPLE-MENTARY THERAPIES, Mary Ann Liebert,Inc., 2 Madison Avenue, Larchmont, NY 10538,(914) 834-3100.