Hawthorn — Crataegus species

Common & Latin Names

Common names: Hawthorn, Haw, May tree, Mayblossom, Whitethorn, Quickthorn, Bread and cheese tree Latin name: Crataegus monogyna Jacq., Crataegus laevigata (Poir.) DC., and Crataegus oxyacantha L. (multiple species and hybrids used medicinally, often collectively referred to as Crataegus spp.) TCM name: Shan Zha (山楂) — refers specifically to Crataegus pinnatifida, the Chinese hawthorn, used as a digestive and blood-moving herb German: Weissdorn French: Aubepine

Plant Family & Parts Used

Family: Rosaceae (rose family — also includes apple, cherry, plum, almond, rose, meadowsweet) Parts used: Berries (haws), leaves, and flowers — all three contain active compounds, but in different proportions. Modern standardized extracts (WS 1442, LI 132) typically use a combination of leaves and flowers, which have the highest concentration of oligomeric procyanidins (OPCs). The berries are used in traditional preparations and are the primary medicinal part in TCM (Shan Zha). Habitat: Native throughout temperate regions of the Northern Hemisphere — Europe, North America, and East Asia. Extremely common in hedgerows, woodland margins, and open ground across Britain and Continental Europe. A thorny deciduous shrub or small tree growing to 5-15 meters, capable of living 400+ years. The oldest hawthorn trees in Britain are living witnesses to medieval history.

Traditional Uses

European Folk Medicine and Herbalism (1,000+ years)

Hawthorn has a deep and intertwined relationship with European culture, mythology, and medicine:

Medieval and Renaissance: Hawthorn was associated with the heart — both literally and symbolically. The “heart remedy” association was well established by the Middle Ages. Dioscorides (1st century CE) did not emphasize cardiac use, but by the 15th-16th centuries, European herbalists including Paracelsus were using hawthorn berries and flowers for heart palpitations, chest pain, and “weakness of the heart.” The symbolic association with the heart (hawthorn flowers on May Day, the “heart” of the hedge, the thorns like the Sacred Heart) merged with genuine pharmacological observation.

Irish physician Green (1820s): Dr. Green of Ennis, Ireland, was among the first to document hawthorn’s specific cardiac effects in clinical practice. His reputation for treating heart disease with a “secret remedy” was legendary. After his death, the secret was revealed: hawthorn berry tincture.

Eclectic Medicine: American Eclectic physicians adopted hawthorn in the late 19th century. Finley Ellingwood (1919) described it as “a cardiac tonic of first importance” for “cardiac dilatation, valvular insufficiency, and general cardiac debility.” The Eclectics recognized hawthorn’s gradual, strengthening, non-toxic nature — a tonic rather than a drug.

TCM (Shan Zha — Chinese Hawthorn)

Shan Zha (Crataegus pinnatifida fruit) has a distinct profile in TCM — it is primarily classified as a digestive herb rather than a cardiac herb:

• Resolves food stagnation: Specifically for meat and fatty food stagnation causing epigastric fullness, belching, and diarrhea
• Activates Blood and dispels stasis: Used in gynecological formulas for menstrual pain, postpartum blood stasis, and abdominal pain from blood stagnation
• Reduces lipids and supports the cardiovascular system: Modern Chinese medicine increasingly recognizes Shan Zha’s cardioprotective effects, bridging the gap with Western use

Ayurvedic Integration (Modern)

Not a classical Ayurvedic herb, but modern Ayurvedic practitioners integrate hawthorn as a Hridaya (cardiac tonic) comparable to the indigenous Arjuna (Terminalia arjuna). Its cooling energy and astringent/sour taste align with Pitta-pacifying cardiac support.

British and Celtic Traditions

In Celtic tradition, hawthorn was one of the most sacred trees — associated with Beltane (May Day), the fairy realm, and the threshold between worlds. The “May” in the festival refers to hawthorn (Mayblossom). Hawthorn was considered a tree of the heart in every sense — emotional, spiritual, and physical. This is not merely folklore; the consistent cross-cultural association of hawthorn with the heart reflects a deep human intuition about the plant’s pharmacology.

Active Compounds & Pharmacology

Primary Phytochemicals

Oligomeric procyanidins (OPCs) (1-3% of leaf/flower, higher in berries): The primary cardiovascular active compounds. These are condensed tannins — polymers of catechin and epicatechin units. They are potent vasodilators, antioxidants, and positive inotropes (strengthen heart contraction). The standardized extract WS 1442 is standardized to 18.75% OPCs.

Flavonoids (1-2%):

• Hyperoside (quercetin-3-galactoside): The most abundant flavonoid. Antioxidant, anti-inflammatory, cardioprotective.
• Vitexin and vitexin-2”-O-rhamnoside: Anti-inflammatory, anti-ischemic.
• Rutin: Capillary-strengthening, antioxidant.
• Quercetin: Broad-spectrum antioxidant and anti-inflammatory.

Triterpene acids: Ursolic acid, oleanolic acid, crataegolic acid. Anti-inflammatory, anti-atherogenic, and hypoglycemic.

Phenolic acids: Chlorogenic acid, caffeic acid. Antioxidant.

Amines: Phenethylamine, tyramine, O-methoxyphenethylamine. Mild cardiotonic and CNS effects. Present primarily in flowers.

Mechanisms of Action

1. Positive Inotropy (Strengthens Heart Contraction): OPCs and flavonoids increase the force of myocardial contraction through phosphodiesterase III (PDE III) inhibition and enhancement of calcium sensitivity in cardiac myocytes. Unlike digitalis, which works by Na+/K+ ATPase inhibition (with narrow therapeutic window and toxicity risk), hawthorn’s positive inotropic effect is gentle, gradual, and non-toxic. It increases contractile force by approximately 10-15% — enough to be clinically meaningful without arrhythmia risk.

2. Vasodilation (Nitric Oxide Mediated): OPCs stimulate endothelial nitric oxide synthase (eNOS), increasing nitric oxide production. This causes vasodilation in both coronary arteries (increasing myocardial blood supply) and peripheral arteries (reducing afterload). The vasodilatory effect reduces the work the heart must perform to pump blood.

3. ACE Inhibition: Hawthorn extracts inhibit angiotensin-converting enzyme (ACE), reducing angiotensin II formation. This lowers blood pressure, reduces aldosterone-mediated fluid retention, and decreases cardiac remodeling. The ACE-inhibitory effect is mild compared to pharmaceutical ACE inhibitors (lisinopril, enalapril) but clinically additive.

4. Anti-arrhythmic: Hawthorn prolongs the refractory period of cardiac myocytes and stabilizes cardiac electrical conduction. It has been shown to reduce the frequency of premature ventricular contractions (PVCs) and supraventricular tachycardia.

5. Anti-atherogenic: OPCs and flavonoids inhibit LDL oxidation (a critical step in atherosclerotic plaque formation), reduce endothelial adhesion molecule expression (preventing monocyte attachment to vessel walls), and stabilize existing atherosclerotic plaques.

6. Antioxidant (Cardiovascular-Specific): The OPCs and flavonoids are particularly concentrated in cardiac and vascular tissue. They protect myocardial cells from ischemia-reperfusion injury, reduce oxidative stress in the vessel wall, and preserve endothelial function under inflammatory conditions.

Clinical Evidence

Key Clinical Trials

Pittler, M.H., Guo, R., & Ernst, E. (2008). “Hawthorn extract for treating chronic heart failure.” Cochrane Database of Systematic Reviews, (1), CD005312.

• Cochrane systematic review — the gold standard of evidence synthesis
• 14 RCTs involving 855 patients with chronic heart failure (NYHA class I-III)
• Hawthorn extract WS 1442 (900mg/day) significantly improved maximal workload (weighted mean difference: +5.35 watts, 95% CI: 0.71-10.0, p=0.02) vs. placebo
• Significantly improved exercise tolerance on 6-minute walk test
• Significantly improved symptoms of dyspnea and fatigue (p<0.01)
• Physiological outcome: significant improvement in pressure-heart rate product (a measure of myocardial oxygen demand)
• Adverse events were “infrequent, mild, and transient”
• Concluded: “These results suggest that there is a significant benefit in symptom control and physiologic outcomes from hawthorn extract as an adjunctive treatment for chronic heart failure”

Holubarsch, C.J., Colucci, W.S., Meinertz, T., Gaus, W., & Tendera, M. (2008). “The efficacy and safety of Crataegus extract WS 1442 in patients with heart failure: the SPICE trial.” European Journal of Heart Failure, 10(12), 1255-1263.

• The largest hawthorn clinical trial ever conducted
• 2,681 patients with NYHA class II-III heart failure, WS 1442 (900mg/day) vs. placebo for 24 months
• Primary endpoint (cardiac mortality) was not significantly different between groups in the overall analysis
• However, in the pre-specified subgroup of patients with LVEF >/= 25%, hawthorn reduced cardiac mortality by 39.7% (hazard ratio: 0.603, p=0.029)
• Sudden cardiac death was reduced by 41.8% in the LVEF >/= 25% subgroup (p=0.025)
• No safety concerns — hawthorn was well tolerated even in severely ill heart failure patients on standard medication
• This trial is pivotal: it demonstrates that hawthorn benefits heart failure patients with moderately preserved function and confirms safety in a population on multiple cardiac medications

Tauchert, M. (2002). “Efficacy and safety of Crataegus extract WS 1442 in comparison with placebo in patients with chronic stable New York Heart Association class III heart failure.” American Heart Journal, 143(5), 910-915.

• 209 patients with NYHA class III heart failure, WS 1442 (900mg or 1800mg daily) vs. placebo for 16 weeks
• Both doses significantly improved exercise tolerance (p<0.01)
• Significantly reduced symptoms of ankle edema, dyspnea on exertion, and nocturia
• The higher dose (1800mg) showed a trend toward greater benefit

Walker, A.F., Marakis, G., Simpson, E., et al. (2006). “Hypotensive effects of hawthorn for patients with diabetes taking prescription drugs: a randomised controlled pilot study.” British Journal of General Practice, 56(527), 437-443.

• 79 patients with type 2 diabetes, hawthorn extract (1200mg/day) vs. placebo for 16 weeks
• Significant reduction in diastolic blood pressure in the hawthorn group (p=0.035)
• Trend toward reduction in systolic blood pressure
• Demonstrated cardiovascular benefits specifically in the metabolic syndrome/diabetes population

Therapeutic Applications

Conditions

• Chronic heart failure (NYHA class I-III): Strongest evidence base — improves exercise tolerance, symptoms, and potentially mortality
• Hypertension (mild to moderate): Gentle, well-tolerated BP reduction
• Coronary artery disease: Anti-atherogenic and anti-ischemic effects
• Cardiac arrhythmias (mild): Stabilizes cardiac electrical activity
• Heart palpitations and anxiety-related cardiac symptoms: Calming cardiac tonic
• Peripheral vascular disease: Vasodilatory and circulation-improving effects
• Metabolic syndrome cardiovascular risk: Addresses multiple cardiovascular risk factors
• Post-myocardial infarction recovery: Cardioprotective and anti-remodeling
• Age-related cardiovascular decline: Long-term preventive tonic
• Digestive stagnation (Shan Zha/TCM use): Fatty food stagnation, dyslipidemia

Dosage Ranges

• WS 1442 extract (standardized to 18.75% OPCs): 900mg daily (most studied dose), can increase to 1800mg daily in NYHA class III
• LI 132 extract (standardized to 2.2% flavonoids): 300-900mg daily
• Hawthorn berry tincture (1:5 in 45% alcohol): 3-5mL, 3 times daily
• Leaf and flower tincture (1:5): 2-4mL, 3 times daily
• Dried berries (infusion): 2-5g steeped in hot water for 15-20 minutes, 3 times daily
• Dried leaf and flower (infusion): 1-2g steeped in hot water, covered, 3 times daily
• Shan Zha (TCM): 9-15g in decoction

Forms and Duration

Standardized extracts are preferred for clinical heart failure management. Berry tinctures and teas are appropriate for general cardiovascular support and prevention. Hawthorn is a slow-acting tonic — effects build over 4-12 weeks. It is intended for long-term, ongoing use — months to years. This is not an acute cardiac intervention but a restorative tonic that gradually strengthens cardiac function.

Safety & Contraindications

Exceptionally Well Tolerated

Hawthorn has one of the best safety profiles of any cardiovascular botanical. In the SPICE trial (2,681 patients over 24 months), adverse events were no different from placebo. Even in severely ill heart failure patients taking digoxin, diuretics, ACE inhibitors, and beta-blockers simultaneously, hawthorn added no adverse effects.

Contraindications

• Known allergy to Rosaceae family: Rare but possible cross-reactivity.
• NYHA class IV heart failure: While not directly contraindicated, very severe heart failure requires close medical supervision. Hawthorn is not a substitute for standard heart failure therapy.

Drug Interactions

• Digoxin: Hawthorn may potentiate digoxin’s positive inotropic effect. In practice, the combination has been used safely in clinical trials (SPICE trial), but monitoring of digoxin levels is recommended.
• Beta-blockers: Additive negative chronotropic effect (heart rate slowing). Generally safe in combination but monitor heart rate.
• ACE inhibitors/ARBs: Additive blood pressure lowering. Generally beneficial in combination.
• Antihypertensives: Additive hypotensive effect. Monitor blood pressure.
• PDE5 inhibitors (sildenafil): Theoretical additive vasodilation. Caution.
• Nitrates: Additive vasodilation. Caution.
• CNS depressants: Mild additive sedative effect at high hawthorn doses.

Pregnancy and Lactation

Insufficient clinical data. Traditionally considered safe as a food (hawthorn berries are edible and widely consumed), but the concentrated extracts used for cardiac conditions are not recommended during pregnancy without practitioner guidance.

Side Effects (Rare)

Mild GI discomfort, dizziness (from vasodilation/BP reduction), headache, nausea, and palpitations (paradoxically — usually in the first 1-2 weeks, typically resolving). These occur in <5% of users and are usually transient.

Energetics

TCM Classification (Shan Zha)

• Temperature: Slightly warm
• Flavor: Sour, sweet
• Meridian entry: Spleen, Stomach, Liver
• Actions: Resolves food stagnation (especially from meat and fat), activates Blood and dispels stasis, reduces lipids
• TCM pattern correspondence: Food stagnation in the Middle Jiao (bloating, fullness, nausea after eating rich food), Blood stasis (amenorrhea, postpartum pain, cardiovascular stasis)

Western Energetic Classification (Crataegus monogyna/laevigata)

• Temperature: Slightly cool to neutral
• Flavor: Sour, astringent, sweet
• Organ affinity: Heart (physical and energetic), cardiovascular system
• Actions: Tonifies and strengthens the Heart, opens the chest, moves stagnant Heart Blood and Qi, calms the spirit

Ayurvedic Classification (Modern Integration)

• Rasa (taste): Amla (sour), Kashaya (astringent), Madhura (sweet)
• Virya (energy/potency): Shita (slightly cooling)
• Vipaka (post-digestive effect): Madhura (sweet)
• Dosha effects: Pacifies Pitta (cooling, astringent). Pacifies Vata (grounding, nourishing to the heart). May reduce Kapha in mild doses (astringent, blood-moving).
• Dhatu affinity: Rakta (blood), Mamsa (muscle — specifically cardiac muscle), Meda (fat — via lipid reduction)
• Srotas affinity: Raktavaha (blood channels), Hridaya (heart)

Functional Medicine Integration

Hawthorn is the premier long-term cardiovascular tonic in functional medicine — the botanical equivalent of “cardiac rehabilitation in a capsule.” Its multi-target mechanism addresses the interconnected web of cardiovascular dysfunction.

Cardiovascular Prevention Protocol

For patients with cardiovascular risk factors (hypertension, dyslipidemia, metabolic syndrome, family history), hawthorn provides comprehensive, gentle, long-term protection: mild BP reduction, LDL oxidation inhibition, endothelial function improvement, and anti-inflammatory effects. It is the cardiovascular equivalent of ashwagandha for stress — a foundational, long-term support herb rather than an acute intervention.

Heart Failure Support Protocol

Based on the Cochrane review (Pittler 2008) and SPICE trial (Holubarsch 2008), hawthorn is an evidence-based adjunct to standard heart failure medications. It improves exercise tolerance, reduces symptoms, and may reduce mortality in patients with moderately preserved ejection fraction. In functional medicine, it is used alongside CoQ10, D-ribose, magnesium, and fish oil in comprehensive cardiac support programs.

Metabolic Syndrome Cardiovascular Protocol

The metabolic syndrome patient with hypertension, dyslipidemia, and insulin resistance needs multi-target cardiovascular support. Hawthorn addresses the vascular dysfunction (endothelial improvement, vasodilation, anti-atherogenic) while berberine addresses the metabolic dysfunction. Together, they provide complementary cardiovascular-metabolic protection.

Anxiety-Related Cardiac Symptoms

Palpitations, chest tightness, and “heart anxiety” (the fear of cardiac events) are extremely common in functional medicine practice. Hawthorn calms these symptoms through its anti-arrhythmic, vasodilatory, and gentle sedative effects. It is the physical medicine for the anxious heart. Combined with lemon balm, passionflower, and magnesium, it addresses both the cardiac symptoms and the anxiety driving them.

Grief and Heartbreak Protocol

Every herbalist recognizes hawthorn as the herb for a “broken heart” — not metaphorically, but clinically. Chronic grief and emotional heartbreak manifest as cardiac symptoms (palpitations, chest pain, shortness of breath) and increase cardiovascular disease risk through chronic sympathetic activation and cortisol elevation. Hawthorn treats both the physical cardiac vulnerability and the energetic “openness of the heart” that grief demands.

Four Directions Connection

Primary Direction: Jaguar (West — Emotional Healing)

Hawthorn is the Jaguar’s heart medicine. The Jaguar governs the emotional body — grief, loss, love, fear, and the courage to keep the heart open despite pain. Hawthorn is the herb of the wounded heart — the heart that has been broken by loss, betrayal, or grief and yet must continue beating. In every tradition, hawthorn is associated with the threshold between love and loss, between life and death, between the seen and unseen worlds. The Jaguar teaches us that the heart must remain open to transform, even when it hurts. Hawthorn physically and energetically supports this teaching — it strengthens the heart while keeping it open.

Secondary Direction: Serpent (South — Physical Body)

The physical heart is the Serpent’s most vital organ — the ceaseless pump that sustains all life in the body. When the heart weakens (heart failure, coronary disease, arrhythmia), the Serpent’s fundamental vitality is threatened. Hawthorn addresses this threat at the tissue level: strengthening contraction, improving coronary blood flow, protecting myocardial cells from oxidative damage, and stabilizing the electrical rhythm. It is Serpent medicine in its most life-sustaining form.

Tertiary: Eagle (East — Spiritual Vision)

In Celtic and European traditions, hawthorn is the fairy tree — the tree that stands at the boundary between the physical world and the spirit world. It is the Eagle’s tree because it connects the earthly heart to the spiritual heart. The Eagle sees from the highest perspective, and hawthorn opens the inner vision that comes through the heart. In many contemplative traditions, the “heart center” is the seat of spiritual perception. Hawthorn, by calming and strengthening this center, creates the conditions for spiritual opening.

References

1. Pittler, M.H., Guo, R., & Ernst, E. (2008). Hawthorn extract for treating chronic heart failure. Cochrane Database of Systematic Reviews, (1), CD005312.

2. Holubarsch, C.J., Colucci, W.S., Meinertz, T., Gaus, W., & Tendera, M. (2008). The efficacy and safety of Crataegus extract WS 1442 in patients with heart failure: the SPICE trial. European Journal of Heart Failure, 10(12), 1255-1263.

3. Tauchert, M. (2002). Efficacy and safety of Crataegus extract WS 1442 in comparison with placebo in patients with chronic stable New York Heart Association class III heart failure. American Heart Journal, 143(5), 910-915.

4. Walker, A.F., Marakis, G., Simpson, E., et al. (2006). Hypotensive effects of hawthorn for patients with diabetes taking prescription drugs. British Journal of General Practice, 56(527), 437-443.

5. Tassell, M.C., Kingston, R., Gilroy, D., Lehane, M., & Furey, A. (2010). Hawthorn (Crataegus spp.) in the treatment of cardiovascular disease. Pharmacognosy Reviews, 4(7), 32-41.

6. Edwards, J.E., Brown, P.N., Talent, N., Dickinson, T.A., & Shipley, P.R. (2012). A review of the chemistry of the genus Crataegus. Phytochemistry, 79, 5-26.

7. Chang, Q., Zuo, Z., Harrison, F., & Chow, M.S.S. (2002). Hawthorn. Journal of Clinical Pharmacology, 42(6), 605-612.

8. Koch, E., & Malek, F.A. (2011). Standardized extracts from hawthorn leaves and flowers in the treatment of cardiovascular disorders — preclinical and clinical studies. Planta Medica, 77(11), 1159-1167.

9. Degenring, F.H., Suter, A., Weber, M., & Saller, R. (2003). A randomised double blind placebo controlled clinical trial of a standardised extract of fresh Crataegus berries in the treatment of patients with congestive heart failure NYHA II. Phytomedicine, 10(5), 363-369.

10. Daniele, C., Mazzanti, G., Pittler, M.H., & Ernst, E. (2006). Adverse-event profile of Crataegus spp.: a systematic review. Drug Safety, 29(6), 523-535.