Herbal Monograph
Hawthorn
Crataegus monogyna Jacq.
Rosaceae
The heart's botanical ally — centuries of traditional use validated by modern cardiology research.
Overview
Plant Description
Thorny deciduous shrub or small tree, typically 5-14 m tall, with a dense, rounded crown. Bark greyish-brown, becoming fissured and scaly with age. Branches armed with stout, sharp thorns 1-2.5 cm long (modified short shoots). Leaves alternate, 2-6 cm long, deeply lobed (3-7 lobes extending more than halfway to the midrib in C. monogyna; shallower lobes in C. laevigata), dark glossy green above, paler below. Stipules present, curved, toothed. Flowers are borne in dense, flat-topped corymbs of 5-25 flowers in late spring (May in the Northern Hemisphere, hence 'May blossom'). Individual flowers 8-15 mm across with 5 white petals (occasionally pink), numerous red-anthered stamens (approximately 20), and a characteristic sweet yet slightly fetid scent due to trimethylamine. Fruit (haw) is an ovoid to globose pome, 6-14 mm long, deep red to dark crimson when ripe (September-November), with mealy flesh and 1 seed (C. monogyna) or 2 seeds (C. laevigata). The plant is extremely long-lived; specimens exceeding 400 years are documented. Hybridization between C. monogyna and C. laevigata is common where ranges overlap, producing intermediate forms (C. x media Bechst.).
Habitat
Hedgerows, woodland margins, scrubland, limestone cliffs, and open hillsides. Highly adaptable species tolerating a wide range of soil types including chalk, clay, and sandy soils (pH 4.5-8.0). Prefers well-drained soils in full sun to partial shade. Hardy to USDA zones 4-8. Drought-tolerant once established. An important pioneer species in ecological succession, colonizing open ground and providing shelter for other tree seedlings. Historically planted as hedging ('quickset' hedging) across Britain and Europe.
Distribution
Native to Europe, northwestern Africa, and western Asia. C. monogyna ranges from Scandinavia south to the Mediterranean, east to the Caucasus and Iran. C. laevigata has a more restricted distribution in western and central Europe. Naturalized and sometimes invasive in parts of North America, Australia, New Zealand, and South America. Major commercial cultivation and wild harvest for medicinal use in Germany, Poland, Hungary, Romania, Bulgaria, and Turkey. Germany is the principal market for hawthorn medicinal products.
Parts Used
Flowering tops (Crataegi folium cum flore — leaves with flowers)
Preferred: Standardized hydroalcoholic extract (e.g., WS 1442), dried for infusion, tincture
The primary pharmacopoeial drug form in European practice. The European Pharmacopoeia, ESCOP, and EMA monographs all specify the leaf-with-flower preparation as the standard medicinal material. This combined drug form provides the fullest spectrum of bioactive flavonoids and oligomeric proanthocyanidins (OPCs). The clinically studied WS 1442 extract is derived from this drug. Flowering tops are considered to have the highest concentration of vitexin, hyperoside, and OPCs compared to berries or leaves alone.
Berries (Crataegi fructus — haws)
Preferred: Tincture, syrup, decoction, dried for infusion
Traditionally the most commonly used part in both European folk medicine and TCM (C. pinnatifida). Rich in OPCs, flavonoids (particularly hyperoside), and organic acids. The berry drug was historically more commonly used in British herbalism and folk medicine. Some commercial products use berry extracts or a combination of berry and leaf-flower extracts. EMA acknowledges traditional use of both the berry and the leaf-with-flower drug. Berry preparations may have a somewhat different constituent profile from leaf-flower preparations, with different ratios of specific flavonoids.
Leaves (Crataegi folium)
Preferred: Dried for infusion, tincture (usually combined with flowers or berries)
Used alone less commonly than the leaf-with-flower combination, but contain significant quantities of flavonoids and OPCs. In some traditional preparations, leaves are harvested separately in spring or summer. The leaf alone is not the standard pharmacopoeial drug in the European Pharmacopoeia, but is acceptable in some traditional product formulations.
Key Constituents
Oligomeric proanthocyanidins (OPCs / procyanidins)
OPCs are considered, alongside flavonoids, the primary cardiovascular-active constituents in hawthorn. The WS 1442 extract is standardized to 18.75% OPCs. OPCs demonstrate positive inotropic activity (increased force of cardiac contraction without increased oxygen demand), coronary vasodilation, endothelium-dependent vasorelaxation via nitric oxide potentiation, and potent antioxidant effects that protect against LDL oxidation and endothelial damage. The OPC content is a key quality parameter differentiating pharmaceutical-grade hawthorn extracts from inferior products.
Flavonoids (flavone and flavonol glycosides)
Flavonoids are the second major group of cardiovascular-active constituents in hawthorn, working synergistically with OPCs. Total flavonoid content (calculated as hyperoside) is a standard pharmacopoeial quality parameter; the European Pharmacopoeia requires a minimum of 1.5% total flavonoids in the leaf-with-flower drug. The LI 132 extract is standardized to 2.2% flavonoids. Flavonoids contribute to coronary vasodilation, positive inotropic activity, antiarrhythmic effects, and antioxidant protection. The combination of flavonoids and OPCs is believed to produce synergistic cardiovascular effects greater than either fraction alone.
Triterpenic acids
Triterpenic acids contribute to hawthorn's anti-inflammatory and cardioprotective activity. While less studied than the flavonoids and OPCs, ursolic and oleanolic acids demonstrate cardiovascular benefits in animal models including improved myocardial contractility, reduced cardiac fibrosis, and anti-atherosclerotic effects. They also contribute to hawthorn's mild anti-inflammatory and antioxidant properties.
Phenolic acids and other constituents
Phenolic acids contribute to hawthorn's overall antioxidant capacity and may enhance the bioavailability of flavonoids and OPCs. Chlorogenic acid is a significant antioxidant constituent. The organic acids in berries, particularly ascorbic acid, provide additional antioxidant support. Biogenic amines are present in trace amounts only and are not considered therapeutically significant at normal doses.
Herbal Actions
Strengthens and tones the heart muscle
The most well-established and clinically validated action of hawthorn. Exerts a positive inotropic effect (increases force of cardiac contraction) without increasing myocardial oxygen demand -- a critical pharmacological distinction from cardiac glycosides. Mechanism involves inhibition of phosphodiesterase (increasing intracellular cAMP) and enhancement of coronary blood flow. Multiple clinical trials (WS 1442 and LI 132 extracts) demonstrate improved cardiac output, reduced peripheral vascular resistance, and improved exercise tolerance in patients with heart failure NYHA class I-III. The cardiotonic action is attributed to the synergistic effects of OPCs and flavonoids.
[3, 4, 6, 7]Lowers blood pressure
Hawthorn reduces blood pressure through multiple mechanisms: endothelium-dependent vasorelaxation via nitric oxide potentiation, ACE-inhibitory activity (demonstrated in vitro), reduction in peripheral vascular resistance, and mild diuretic effects. Clinical trials in hypertensive patients show modest but consistent reductions in systolic and diastolic blood pressure. Walker et al. 2002 RCT (n=36 mildly hypertensive patients): hawthorn extract 500 mg/day for 10 weeks significantly reduced resting diastolic blood pressure compared to placebo. The hypotensive effect is gradual and mild, making hawthorn suitable for mild hypertension and as an adjunct to conventional antihypertensive therapy.
[4, 8, 14]Prevents or slows oxidative damage to cells
Potent antioxidant activity attributable to OPCs, flavonoids, and phenolic acids. Hawthorn extracts inhibit LDL oxidation, reduce lipid peroxidation, and scavenge reactive oxygen species. OPCs are particularly effective at protecting endothelial cells from oxidative damage. Antioxidant activity is central to hawthorn's cardioprotective mechanism, as oxidative stress is a key driver of atherosclerosis, endothelial dysfunction, and myocardial damage. In vitro ORAC values for hawthorn berry extracts are among the highest for commonly used medicinal plants.
[11, 12]Reduces inflammation
Flavonoids and triterpenic acids (ursolic acid, oleanolic acid) demonstrate anti-inflammatory activity via inhibition of COX-2, 5-LOX, and NF-kB signaling pathways. Reduces vascular inflammation and may slow atherosclerotic plaque progression. Anti-inflammatory effects contribute to cardiovascular protection and may underlie some of the observed benefits in heart failure. Less extensively studied clinically than the cardiotonic action.
[12]Relieves smooth muscle spasm
Relaxes vascular smooth muscle, contributing to vasodilation and blood pressure reduction. Also demonstrates spasmolytic activity on gastrointestinal smooth muscle. Mechanism involves calcium channel antagonism and potentiation of nitric oxide-mediated relaxation. The antispasmodic action on coronary arteries contributes to hawthorn's anti-anginal properties.
[3, 14]Reduces anxiety
Mild anxiolytic activity demonstrated in clinical studies. Hanus et al. 2004 RCT (n=264): a combination of hawthorn, Californian poppy, and magnesium significantly reduced anxiety scores. Hawthorn is traditionally indicated for anxiety-related cardiac symptoms ('nervous heart') including palpitations, tachycardia, and chest tightness associated with anxiety. The anxiolytic mechanism is not fully elucidated but may involve modulation of GABA pathways and reduction of sympathetic nervous system activity on the heart.
[9, 14]Tightens and tones tissue, reduces secretions
Mild astringent action due to tannin and proanthocyanidin content. Contributes to traditional use in diarrhea and as a gargle for sore throat. The astringent action is more pronounced in berry preparations than in leaf-flower preparations. Not a primary therapeutic action in modern clinical use.
[14]Therapeutic Indications
Cardiovascular System
Chronic heart failure (NYHA functional class I-III)
The most extensively studied clinical indication for hawthorn. Pittler et al. 2003 Cochrane review of 14 RCTs found hawthorn extract significantly improved maximal workload (weighted mean difference +7 watts, 95% CI 3.0-10.6), exercise tolerance, and subjective symptoms (dyspnea, fatigue) compared to placebo. The SPICE trial (Holubarsch et al. 2008), the largest hawthorn trial (n=2681, NYHA II-III), found that WS 1442 (900 mg/day) did not significantly reduce the primary composite endpoint of cardiac death but showed a significant 39.7% reduction in sudden cardiac death in a pre-specified subgroup (NYHA III, LVEF >= 25%). EMA and ESCOP monographs support traditional use for declining cardiac performance corresponding to NYHA I-II. Hawthorn is used as an adjunct to, not replacement for, standard heart failure pharmacotherapy.
[3, 4, 6, 7]Hypertension (mild to moderate)
Walker et al. 2002 RCT (n=36): hawthorn 500 mg/day for 10 weeks significantly reduced resting diastolic blood pressure (mean reduction 2.6 mmHg, P=0.035) compared to placebo. Asgary et al. 2004 clinical study showed reductions in both systolic and diastolic blood pressure with hawthorn extract. The hypotensive mechanism involves nitric oxide-mediated vasodilation, ACE inhibition, and reduced peripheral vascular resistance. The blood pressure-lowering effect is modest and gradual; hawthorn is best used for mild hypertension or as an adjunct to conventional antihypertensives, particularly where anxiety-related sympathetic drive contributes to elevated blood pressure.
[4, 8]Atherosclerosis and coronary artery disease
Hawthorn's antioxidant flavonoids and OPCs inhibit LDL oxidation, a key initiating event in atherosclerosis. Animal studies demonstrate reduced aortic plaque formation with hawthorn extract supplementation. Anti-inflammatory effects (COX-2 and NF-kB inhibition) further support anti-atherosclerotic activity. Epidemiological and mechanistic evidence is supportive; dedicated clinical endpoint trials for atherosclerosis prevention are lacking. Hawthorn is used as part of a comprehensive cardiovascular support strategy rather than as a sole anti-atherosclerotic agent.
[11, 12]Angina pectoris (stable)
Improved coronary blood flow and reduced myocardial oxygen consumption underlie hawthorn's anti-anginal effect. Weng et al. 1984 Chinese clinical study of C. pinnatifida showed significant symptomatic improvement in angina patients. Hawthorn's positive inotropic effect without increased oxygen demand, combined with coronary vasodilation and antispasmodic activity on coronary smooth muscle, provides a sound pharmacological basis for this indication. Used adjunctively to conventional angina management; not a substitute for acute anti-anginal therapy (nitroglycerin).
[3, 14]Cardiac arrhythmias (mild, functional)
Hawthorn has demonstrated antiarrhythmic properties in animal models, including prolongation of the effective refractory period and suppression of ectopic pacemaker activity. Mechanism involves potassium and calcium channel modulation. Traditionally used for palpitations and mild tachyarrhythmias, particularly those associated with anxiety or autonomic dysfunction. Clinical trial evidence specifically for arrhythmia management is limited. Not a substitute for antiarrhythmic drugs in clinically significant arrhythmias.
[3, 14]Functional cardiovascular complaints (nervous heart, cardiac anxiety)
One of hawthorn's most traditional and widely recognized indications. 'Herzinsuffizienz' in the German tradition encompasses both organic and functional heart complaints. Hawthorn is particularly valued for patients presenting with palpitations, mild tachycardia, chest tightness, or exertional dyspnea in the absence of severe structural heart disease -- often related to anxiety, stress, or autonomic imbalance. EMA traditional-use monograph specifically includes 'traditional herbal medicinal product for the relief of symptoms of temporary nervous cardiac complaints (e.g. palpitations, perceived extra heartbeats due to mild anxiety) after serious conditions have been excluded by a medical doctor.'
[1, 4, 9]Nervous System
Anxiety with cardiovascular symptoms
Hanus et al. 2004 RCT (n=264): a fixed combination of hawthorn extract (75 mg), Californian poppy (20 mg), and magnesium (75 mg) taken twice daily for 3 months significantly reduced anxiety scores (Hamilton Anxiety Rating Scale) compared to placebo (P<0.005). While hawthorn was used in combination, its traditional use specifically for anxiety-related cardiac symptoms (palpitations, tachycardia) is well-established in European herbalism. The mechanism may involve mild sedative-anxiolytic effects combined with direct cardiac-stabilizing activity that reduces the somatic manifestations of anxiety.
[9, 14]Digestive System
Food stagnation and dyspepsia (TCM — C. pinnatifida)
In TCM, Shan Zha (C. pinnatifida) is one of the principal herbs for food stagnation, particularly stagnation from excessive consumption of meat and greasy foods. It promotes digestion, disperses food accumulation, and transforms blood stasis. Listed in the Chinese Pharmacopoeia for this indication. The European species (C. monogyna/C. laevigata) are not primarily used for digestive indications in Western herbalism, though the berry preparations have mild digestive-stimulating properties due to their organic acid content and bitter-sour taste.
[13]Energetics
Temperature
slightly warm
Moisture
dry
Taste
Tissue States
lax/atony, damp/stagnation
In Western energetic terms, hawthorn is slightly warming with a tonic, restorative quality particularly directed toward the heart and vasculature. Its sour-sweet-astringent taste profile reflects the combined influence of organic acids, sugars, and tannins (particularly in the berries). Energetically, hawthorn is considered a trophorestorative for the cardiovascular system -- it nourishes and gradually restores function rather than providing immediate stimulant effects. Indicated for conditions of cardiac weakness, laxity, and circulatory stagnation. In TCM (C. pinnatifida / Shan Zha), the berries are classified as warm in temperature, sour and sweet in taste, entering the spleen, stomach, and liver channels. The Chinese species is used primarily for food stagnation and blood stasis rather than direct cardiac tonification. In the Galenic/Unani tradition, hawthorn is warm and dry in the first degree. Matthew Wood and other Western vitalist herbalists describe hawthorn as a remedy for 'broken hearts' -- both emotional grief and physical cardiac weakness -- emphasizing its gentle, restorative energetics.
Traditional Uses
European Folk Medicine and Western Herbalism
- Cardiac tonic for age-related heart weakness and declining cardiac performance
- Treatment for 'nervous heart' -- palpitations, chest tightness, and tachycardia associated with anxiety and emotional stress
- Berries eaten raw or as preserves as a general cardiovascular tonic and food in winter
- Infusion of flowering tops for mild hypertension and circulatory support
- Berry syrup or decoction for sore throat and as a mild astringent for diarrhea
- Emotional heart remedy: traditionally associated with grief, heartbreak, and emotional protection (the thorn as protector of the heart)
- Combined with linden (Tilia) and motherwort (Leonurus cardiaca) for heart conditions with anxiety
"Hawthorn has been used for heart conditions in European folk medicine since at least the Middle Ages. Dioscorides (1st century CE) mentioned Crataegus but primarily for its astringent properties rather than cardiac use. The cardiac application became prominent in the 17th-19th centuries. Gerard's Herball (1597) mentioned hawthorn berries as a remedy for 'the stone' and pleurisy. In Ireland, hawthorn was considered a fairy tree with powerful protective magic, and cutting one was believed to bring misfortune. The modern clinical use of hawthorn for heart conditions was pioneered by Dr. Green of Ennis, Ireland, in the late 19th century, whose secret cardiac remedy was revealed after his death in 1894 to be a tincture of ripe hawthorn berries."
[14]
Traditional Chinese Medicine (TCM)
- Shan Zha (C. pinnatifida): Disperse food accumulation, especially stagnation from meat and greasy foods
- Shan Zha: Invigorate blood and transform blood stasis (used for postpartum abdominal pain, hernial pain, amenorrhea with blood stasis)
- Shan Zha: Treat dysenteric disorders (charred form -- Jiao Shan Zha -- for diarrhea with food stagnation)
- Shan Zha: Reduce hyperlipidemia (modern TCM application)
- Shan Zha: Treat hypertension (modern TCM application, often combined with other herbs)
"C. pinnatifida (Shan Zha) is listed in the Chinese Pharmacopoeia and described in classical texts including Ben Cao Gang Mu (Li Shizhen, 1596). Classified as warm in nature, sour and sweet in taste. Enters the spleen, stomach, and liver channels. Primary action is to reduce food stagnation. The blood-moving (huo xue) property is secondary but clinically significant in TCM, distinguishing it from the European use which focuses almost exclusively on cardiac tonification. Charred hawthorn (Jiao Shan Zha) is used for diarrhea -- charring converts the sour-dispersing qualities to a more astringent, stool-binding action."
[13]
Eclectic Medicine (19th-early 20th century American)
- Cardiac tonic for functional and organic heart disease
- Treatment of valvular heart disease and cardiac dropsy (edema from heart failure)
- Remedy for irregular, feeble, or intermittent pulse
- Tonic for elderly patients with failing cardiac function
- Treatment of angina pectoris and dyspnea on exertion
"Eclectic physicians adopted hawthorn for cardiac use following the revelations about Dr. Green's Irish remedy in the 1890s. J.M. Clement reported favorable results with Crataegus in the Eclectic Medical Journal (1898) for cardiac disease including valvular insufficiency, cardiac dropsy, and irregular heart action. Harvey Wickes Felter in the Eclectic Materia Medica (1922) described Crataegus as 'a remedy of great value in cardiac disorders' particularly for 'cardiac weakness with valvular insufficiency, irregularity of heart action, and dyspnoea.' The Eclectic tradition emphasized its safety, gentle action, and suitability for long-term use in chronic cardiac conditions."
Celtic and British Folk Tradition
- Hawthorn berries and flowering tops as a spring tonic for the heart and blood
- Berries made into wines, jellies, and syrups for winter health
- Young leaves eaten in spring as 'bread and cheese' (children's forage food)
- Protective tree planted near homes to ward off evil spirits and lightning
- Flowers brought into the house considered unlucky (possibly due to trimethylamine scent associated with death/decay)
- May Day celebrations: hawthorn blossom used in garlands and decorations as a symbol of fertility and renewal
"The hawthorn ('may tree') holds a central place in Celtic and British folklore. It was one of the 'fairy triad' trees (oak, ash, thorn) in Irish tradition. Solitary hawthorn trees in fields were considered fairy meeting places and were rarely cut. The association with the month of May and Beltane (May Day) celebrations connects hawthorn to themes of fertility, renewal, and the transition from spring to summer. The superstition against bringing hawthorn flowers indoors may relate to their trimethylamine content, which produces a scent historically associated with death, or may reflect pre-Christian taboos about disturbing fairy trees. Despite this, the berries and young leaves were widely consumed as food and folk medicine."
[14]
Modern Research
Cochrane review of hawthorn extract for chronic heart failure
Cochrane systematic review of 14 randomized, double-blind, placebo-controlled trials evaluating hawthorn extract (predominantly WS 1442 and LI 132) as an adjunctive treatment for chronic heart failure (NYHA I-III).
Findings: Hawthorn extract significantly improved maximal workload capacity (weighted mean difference +7 watts, 95% CI 3.0-10.6, P<0.01), exercise tolerance measured by heart rate-blood pressure product, and subjective symptoms of heart failure (dyspnea, fatigue). Symptom control was significantly improved across multiple trials. Reported adverse events were infrequent, mild, and transient (dizziness, GI complaints, headache).
Limitations: Most included trials were of short to moderate duration (3-16 weeks) with relatively small sample sizes. Heterogeneous extracts and doses used. Most trials studied NYHA I-II patients; evidence for more severe heart failure was limited at the time. The review preceded the SPICE trial results.
[6]
SPICE trial: WS 1442 in symptomatic heart failure
Survival and Prognosis: Investigation of Crataegus Extract WS 1442 in congestive heart failure (SPICE). Large multicenter, randomized, double-blind, placebo-controlled trial of 2681 patients with NYHA class II-III heart failure and reduced LVEF (<=35%). Patients received WS 1442 (900 mg/day) or placebo for 24 months as an add-on to optimal standard heart failure therapy.
Findings: Primary composite endpoint (cardiac mortality) was not significantly different between groups (hazard ratio 0.89, 95% CI 0.73-1.09, P=0.27). However, in a pre-specified subgroup analysis of patients with LVEF >=25%, WS 1442 significantly reduced sudden cardiac death by 39.7% (P=0.025). The extract was well-tolerated with an adverse event profile comparable to placebo. This was the first large outcomes trial of a herbal medicine in heart failure.
Limitations: The primary endpoint was not met. The sudden cardiac death reduction was in a subgroup analysis (though pre-specified). The study population received optimal contemporary heart failure therapy, making it difficult to demonstrate additional benefit. The LVEF >=25% subgroup finding requires confirmation in a dedicated trial.
[7]
Hawthorn extract for blood pressure: randomized controlled trial
Randomized, double-blind, placebo-controlled trial of 36 mildly hypertensive patients (mean diastolic BP 85-95 mmHg) treated with hawthorn extract 500 mg/day or placebo for 10 weeks.
Findings: Hawthorn significantly reduced resting diastolic blood pressure compared to placebo (mean reduction 2.6 mmHg, P=0.035). There was a non-significant trend toward reduced systolic blood pressure. Anxiety levels also tended to be lower in the hawthorn group. No significant adverse effects reported.
Limitations: Small sample size (n=36). Modest blood pressure reduction. Short duration (10 weeks). Studied mildly hypertensive patients only; extrapolation to more severe hypertension is uncertain. The study used a combined magnesium and hawthorn supplement, which may confound interpretation.
[8]
Mechanisms of cardiovascular action: comprehensive review
Comprehensive narrative review of hawthorn's cardiovascular pharmacology, examining molecular mechanisms underlying its cardiotonic, vasodilatory, antioxidant, and cardioprotective effects.
Findings: Hawthorn extracts demonstrate: (1) positive inotropic effect via inhibition of cAMP phosphodiesterase and enhanced calcium sensitivity of myofilaments; (2) endothelium-dependent vasodilation via nitric oxide release and eNOS activation; (3) ACE inhibition (in vitro); (4) antiarrhythmic effects via prolongation of the effective refractory period; (5) antioxidant protection of myocardium and endothelium via free radical scavenging and inhibition of LDL oxidation; (6) anti-inflammatory effects via inhibition of NF-kB, COX-2, and 5-LOX. The combination of OPCs and flavonoids produces synergistic cardiovascular effects greater than either fraction alone.
Limitations: Many mechanisms established in vitro or in animal models. Translation to clinical doses and human pharmacology requires consideration of bioavailability and first-pass metabolism. The synergistic phytochemistry makes it difficult to attribute clinical effects to individual compounds.
Hawthorn for anxiety: combination product RCT
Multicenter, randomized, double-blind, placebo-controlled trial evaluating a fixed combination of hawthorn extract (75 mg), Californian poppy extract (Eschscholzia californica, 20 mg), and magnesium (75 mg), taken twice daily for 3 months in 264 patients with mild-to-moderate generalized anxiety disorder.
Findings: The active treatment significantly reduced Hamilton Anxiety Rating Scale (HAM-A) scores compared to placebo at day 14, day 60, and day 90 (P<0.005 at day 90). The number of patients with HAM-A score <10 (considered remission) was significantly higher in the active group (43.4% vs 24.3%, P<0.01). Treatment was well-tolerated.
Limitations: Combination product: cannot attribute effects to hawthorn alone. Fixed low dose of hawthorn (75 mg bid) -- less than typical cardiovascular doses. Magnesium and Californian poppy both have independent anxiolytic properties. No hawthorn-only arm for comparison.
[9]
Meta-analysis of hawthorn preparations for heart failure
Updated systematic review and meta-analysis of randomized controlled trials evaluating hawthorn leaf-flower extracts as adjunctive treatment for chronic heart failure.
Findings: Pooled analysis confirmed significant improvements in exercise capacity (maximal workload), subjective symptoms (dyspnea-fatigue index), and physiological parameters (heart rate-blood pressure product at submaximal exercise). The evidence was strongest for WS 1442 extract at doses of 900 mg/day and LI 132 at 600-900 mg/day. Hawthorn was consistently well-tolerated with adverse events comparable to placebo in most trials.
Limitations: Heterogeneity in extract types, doses, and outcome measures. Most trials of short-to-moderate duration. Limited data on long-term outcomes and mortality. Evidence strongest for NYHA I-II; less robust for NYHA III.
Preparations & Dosage
Standardized Extract
Strength: WS 1442: drug-extract ratio 4-6.6:1, extraction solvent ethanol 45% w/w, standardized to 18.75% OPCs. LI 132: drug-extract ratio 4-7:1, extraction solvent ethanol 45%, standardized to 2.2% flavonoids calculated as hyperoside.
Commercially prepared standardized hydroalcoholic extract of hawthorn leaf-with-flower (Crataegi folium cum flore). The two most clinically studied extracts are WS 1442 (standardized to 18.75% OPCs, manufactured by Dr. Willmar Schwabe) and LI 132 (standardized to 2.2% flavonoids). These are the preparations with the strongest clinical evidence.
WS 1442: 900 mg/day in 2 divided doses (450 mg bid). LI 132: 300 mg 2-3 times daily (600-900 mg/day total). Other standardized products: follow manufacturer's dosing based on standardization level; typical range 160-900 mg/day of extract.
Twice daily (bid) for WS 1442; 2-3 times daily for LI 132 and other extracts
Minimum 6-8 weeks for initial assessment of efficacy. Benefits increase over time with continued use. Long-term use (months to years) is typical and supported by clinical trial durations of up to 24 months (SPICE trial). EMA monograph notes that if symptoms persist beyond 6 weeks or worsen, medical advice should be sought.
Not established. Not recommended for children under 18 due to insufficient safety data.
Standardized extracts are the preparation form with the strongest clinical evidence. WS 1442 is the most extensively studied hawthorn preparation worldwide. The standardization to OPCs (WS 1442) or flavonoids (LI 132) ensures consistent dosing of bioactive constituents. Not all hawthorn extracts on the market are equivalent -- different extraction solvents, drug-extract ratios, and standardization methods yield products with different constituent profiles. For cardiovascular indications, a clinically validated standardized extract is strongly preferred over non-standardized preparations.
Tincture
Strength: Flowering tops: 1:5 in 45% ethanol (dried). Berries: 1:5 in 45% ethanol (dried). Fresh preparations at correspondingly lower ratios (1:2 to 1:3).
Macerate hawthorn flowering tops (fresh or dried) or berries in ethanol-water. For flowering tops: 1:5 in 45% ethanol (dried) or 1:2 in 45% ethanol (fresh). For berries: 1:5 in 45% ethanol (dried) or 1:3 in 25-45% ethanol (fresh berries). Macerate for 2-4 weeks, shaking regularly. Press and filter.
2-5 mL, 3 times daily. Berry tincture and leaf-flower tincture may be combined.
3 times daily, preferably before or between meals
Continuous long-term use is traditional for cardiovascular support. Minimum 8-12 weeks to assess efficacy for chronic cardiac conditions.
Not established. Not typically used in children.
Tincture is the most common traditional preparation in Western herbalism, particularly for cardiac indications. The 45% ethanol effectively extracts both flavonoids and OPCs. Berry tinctures have a pleasant sweet-sour taste. Many practitioners combine leaf-flower and berry tinctures (e.g., equal parts) for a broader constituent profile. The tincture form allows flexible dosing and easy combination with other cardiovascular herbs (linden flower, motherwort, garlic).
Infusion (Tea)
Strength: 1.5-4 g dried flowering tops or berries per 240 mL water
Steep 1-2 teaspoons (approximately 1.5-4 g) of dried hawthorn flowering tops in 240 mL of just-boiled water for 10-15 minutes, covered. Strain and drink. For berry tea: use 1-2 teaspoons of crushed dried berries, steep or gently simmer for 15-20 minutes.
1-2 cups (240-480 mL), 2-3 times daily
2-3 times daily
Continuous long-term use is traditional. Minimum 8-12 weeks for assessment of cardiovascular benefit.
Not established for cardiac indications.
A gentle, pleasant-tasting preparation suitable for long-term daily use. Berry tea has a mildly sweet-sour flavor. Flowering top tea has a milder, more floral taste. Infusion may extract a lower concentration of OPCs compared to hydroalcoholic preparations, but daily consumption over time provides cumulative benefit. Often combined with linden (Tilia) flowers and/or hibiscus for a pleasant cardiovascular tea blend. The infusion form is well-suited for patients who prefer to avoid alcohol-based preparations.
Syrup
Strength: Concentrated berry decoction with 1:1 honey or sugar
Prepare a strong decoction of hawthorn berries (approximately 100 g dried berries or 200 g fresh berries simmered in 500 mL water for 30-40 minutes). Strain, pressing well to extract berry pulp. Add equal weight of honey or sugar to the strained liquid. Simmer gently until syrupy consistency. Store refrigerated in sterilized bottles.
1-2 tablespoons (15-30 mL), 2-3 times daily
2-3 times daily
Ongoing; prepare fresh batches every 2-3 weeks (refrigerated shelf life)
Children over 6 years: 1-2 teaspoons (5-10 mL), 2-3 times daily. Do not give honey-based syrups to children under 1 year.
A palatable traditional preparation particularly popular in British folk herbalism. The syrup form makes hawthorn berries accessible and enjoyable for daily use. Honey adds its own mild antimicrobial and demulcent properties. This preparation is less potent than standardized extracts but is valued for its pleasant taste and ease of long-term compliance. Can be taken straight, added to warm water, or drizzled on food. Hawthorn berry syrup combined with elderberry (Sambucus nigra) syrup is a popular folk combination for winter cardiovascular and immune support.
[14]
Safety & Interactions
Class 1
Can be safely consumed when used appropriately (AHPA Botanical Safety Handbook)
Contraindications
Rare but theoretically possible. Cross-reactivity with other Rosaceae members (apples, pears, almonds, cherries) may occur in individuals with Rosaceae fruit allergies. No documented cases of anaphylaxis from hawthorn preparations.
Insufficient safety data in pediatric populations. EMA monograph states that use in children and adolescents under 18 years is not recommended due to lack of adequate data. The cardiovascular indications for which hawthorn is primarily used are uncommon in children.
Drug Interactions
| Drug / Class | Severity | Mechanism |
|---|---|---|
| Digoxin and other cardiac glycosides (Cardiac glycosides) | theoretical | Hawthorn and cardiac glycosides both exert positive inotropic effects, though through different mechanisms. Hawthorn acts primarily via phosphodiesterase inhibition (increasing cAMP) while digoxin inhibits Na+/K+-ATPase. Theoretical additive inotropic effects and potential for enhanced toxicity. Some in vitro data suggest hawthorn may affect P-glycoprotein-mediated digoxin transport, but clinical studies have not confirmed pharmacokinetic interactions. |
| Antihypertensive agents (ACE inhibitors, ARBs, calcium channel blockers, beta-blockers) (Antihypertensive agents) | minor | Hawthorn has mild hypotensive properties (vasodilation, ACE inhibition, reduced peripheral resistance). Additive blood pressure-lowering effects are possible when combined with conventional antihypertensives. |
| CNS depressants (benzodiazepines, barbiturates) (CNS depressants) | theoretical | Hawthorn has demonstrated mild anxiolytic and sedative activity. Theoretical additive CNS depression when combined with pharmacological sedatives. |
| Phosphodiesterase-5 inhibitors (sildenafil, tadalafil) (PDE-5 inhibitors) | theoretical | Both hawthorn and PDE-5 inhibitors cause vasodilation and reduce blood pressure. Hawthorn's phosphodiesterase inhibition, while primarily affecting PDE-3 in cardiac tissue, could theoretically augment the vasodilatory effects of PDE-5 inhibitors. |
Pregnancy & Lactation
Pregnancy
insufficient data
Lactation
insufficient data
Pregnancy: Insufficient safety data for use during pregnancy. No teratogenicity studies in humans. Animal reproductive toxicity studies with WS 1442 extract showed no teratogenic effects at doses up to 1600 mg/kg in rats, but human data are lacking. EMA monograph states that use during pregnancy is not recommended due to insufficient data. The cardiovascular indications for hawthorn are not typically relevant in pregnancy. Lactation: Insufficient data on excretion into breast milk. EMA monograph states that use during breastfeeding is not recommended due to insufficient data. Traditional use of hawthorn berries as food during pregnancy and lactation is documented in some folk traditions but this does not constitute evidence of safety for concentrated extract preparations.
Adverse Effects
References
Monograph Sources
- [1] German Commission E (Bundesinstitut fur Arzneimittel und Medizinprodukte). Commission E Monograph: Crataegi folium cum flore (Hawthorn Leaf with Flower) — Positive. Bundesanzeiger (Federal Gazette) (1994)
- [2] World Health Organization. WHO Monographs on Selected Medicinal Plants, Volume 2: Folium cum Flore Crataegi. World Health Organization, Geneva (2002) : 66-82
- [3] European Scientific Cooperative on Phytotherapy (ESCOP). ESCOP Monographs: Crataegi folium cum flore — Hawthorn Leaf and Flower. ESCOP Monographs, 2nd edition. Thieme, Stuttgart (2003)
- [4] Committee on Herbal Medicinal Products (HMPC), European Medicines Agency. European Union herbal monograph on Crataegus spp., folium cum flore. European Medicines Agency (2016)
- [5] National Center for Complementary and Integrative Health (NCCIH). Hawthorn. NCCIH, National Institutes of Health (2020)
Clinical Studies
- [6] Pittler MH, Guo R, Ernst E. Hawthorn extract for treating chronic heart failure. Cochrane Database Syst Rev (2008) ; 1 : CD005312 . DOI: 10.1002/14651858.CD005312.pub2 . PMID: 18254076
- [7] Holubarsch CJ, Colucci WS, Menertz T, Gaus W, Tendera M. The efficacy and safety of Crataegus extract WS 1442 in patients with heart failure: the SPICE trial. Eur J Heart Fail (2008) ; 10 : 1255-1263 . DOI: 10.1016/j.ejheart.2008.10.004 . PMID: 19019730
- [8] Walker AF, Marakis G, Morris AP, Robinson PA. Promising hypotensive effect of hawthorn extract: a randomized double-blind pilot study of mild, essential hypertension. Phytother Res (2002) ; 16 : 48-54 . DOI: 10.1002/ptr.947 . PMID: 11807965
- [9] Hanus M, Lafon J, Mathieu M. Double-blind, randomised, placebo-controlled study to evaluate the efficacy and safety of a fixed combination containing two plant extracts (Crataegus oxyacantha and Eschscholtzia californica) and magnesium in mild-to-moderate anxiety disorders. Curr Med Res Opin (2004) ; 20 : 63-71 . DOI: 10.1185/030079903125002603 . PMID: 14741074
- [10] Guo R, Pittler MH, Ernst E. Hawthorn extract for treating chronic heart failure: a systematic review. Int J Clin Pharmacol Ther (2008) ; 46 : 63-71
- [11] Koch E, Malek FA. Standardized extracts from hawthorn leaves and flowers in the treatment of cardiovascular disorders -- preclinical and clinical studies. Planta Med (2011) ; 77 : 1159-1167 . DOI: 10.1055/s-0030-1270849 . PMID: 21283956
- [12] Edwards JE, Brown PN, Talent N, Dickinson TA, Shipley PR. A review of the chemistry of the genus Crataegus. Phytochemistry (2012) ; 79 : 5-26 . DOI: 10.1016/j.phytochem.2012.04.006 . PMID: 22608128
Traditional Texts
- [13] Bensky D, Clavey S, Stoger E. Chinese Herbal Medicine: Materia Medica (3rd edition). Eastland Press, Seattle (2004)
- [14] Bone K, Mills S. Principles and Practice of Phytotherapy: Modern Herbal Medicine (2nd edition). Churchill Livingstone/Elsevier (2013)
- [15] Felter HW. The Eclectic Materia Medica, Pharmacology and Therapeutics. John K. Scudder, Cincinnati (1922)
Pharmacopeias & Reviews
- [16] European Directorate for the Quality of Medicines (EDQM). European Pharmacopoeia Monograph: Hawthorn leaf and flower — Crataegi folium cum flore. European Pharmacopoeia, 9th edition (2017)
- [17] Chinese Pharmacopoeia Commission. Pharmacopoeia of the People's Republic of China: Shan Zha (Crataegi Fructus). China Medical Science Press, Beijing (2020)
Last updated: 2026-02-26 | Status: review