Congestive Heart Failure

There is considerable experimental and clinical evidence supporting the use of hawthorn as an effective treatment for congestive cardiac failure in patients with slight, mild limitation of activity who are comfortable at rest or with mild exertion (i.e. NYHA class II).

A meta-analysis of rigorous clinical trials of the use of hawthorn extract to treat patients with chronic heart failure (NYHA classes I—111) included eight trials involving Hawthorn 684

632 subjects. The results of the meta-analysis showed that treatment with standard

ised hawthorn extracts produced significant improvement in maximal workload, pressure-heart rate product, as well as symptoms such as dyspnoea and fatigue as compared with placebo (Pittler et al 2003). The hawthorn extract most commonly used in these trials was WS 1442, which is standardised to 18.8% oligomeric procyanidins. In some cases, hawthorn extract was used as an adjunct to standard therapy (such as diuretics) and the daily dose ranged from 160 mg to 1800 mg.

A review of the results of 13 clinical trials published from 1981 to 1996, involving over 839 patients, suggests that a daily dose of 900 mg hawthorn extract improves exercise tolerance, anaerobic threshold and ejection fraction, as well as subjective symptoms (Kraft 2000). Studies comparing hawthorn extract LI 132 (Crataegutt novo 450, 1 tablet twice daily) to the ACE inhibitor captopril suggests that the LI 132 extract is comparable in effectiveness to a dose of 37.5 mg captopril, but may be better tolerated (Tauchert 1994).

These findings are supported by the results of more recent studies. A recent prospective, cohort study involving 952 patients with NYHA stage II heart failure compared the use of theWS 1442 extract of hawthorn either alone or in conjunction with conventional therapy to conventional medication. After 2 years, the hawthorn cohort was found to have similar or more pronounced improvements than the conventional medication group with reduced fatigue, stress dyspnoea, and palpitations along with marked reduction in the use of drugs such as ACE inhibitors, cardiac glycosides, diuretics and beta-blockers (Habs 2004).

In two further double-blind studies of NYHA class II patients, one using the WS 1442 extract in 40 patients (Zapfe 2001) and another using the Rob 10 standardised extract of fresh hawthorn berries in 88 patients (Rietbrock et al 2001), 3 months' treatment with hawthorn led to significantly improved exercise tolerance, reduced subjective symptoms, and was found to be safe and well tolerated. In 2003, another placebo-controlled, randomised, parallel-group, multicentre trial confirmed the efficacy and safety of a standardised extract of fresh berries of Crataegus oxyacantha L. and C. monogyna Jacq. (crataegisan) in patients with cardiac failure NYHA class II (Degenring et al 2003). This study of 143 patients (mean age 64.8 years) used a dose of 30 drops of the extract taken three times daily for 8 weeks and found a significant increase in exercise tolerance, but no difference in symptoms or blood pressure-heart rate product. Researchers suggested that dyspnoea and fatigue do not occur until a significantly higher wattage had been reached in the bicycle exercise testing and that further improvements were likely to occur if treatment time was extended.

In another RCT of patients with marked limitation of activity, who were Hawthorn 685

comfortable only at rest (NYHA class III), 209 patients received standardised extract

WS 1442 at doses of either 900 mg or 1800 mg or placebo in addition to pre-existing diuretic treatment. After 16 weeks, significant dose-dependent improvements in exercise capacity and clinical signs and symptoms were seen with the herbal extract, with patients on the higher dosage experiencing less adverse events such as dizziness and vertigo (Tauchert et al 2002). A large, international, multicentre double-blind study is investigating the influence of theWS 1442 extract on mortality of up to 2300 cardiac patients over 24 months (Holubarsch et al 2000).

In an observational cohort study of 212 patients, a homeopathic hawthorn preparation was found to be non-inferior to standard treatment (ACE inhibitor/diuretics) for mild cardiac insufficiency in all parameters except blood pressure reduction (Schroder et al 2003).

As well as being shown to be effective when used alone, hawthorn is effective in reducing symptoms of congestive heart failure when used in combination with other herbs such as camphor. This was demonstrated in an open study of 319 patients (Harder & Rietbrock 1990), as well as in a double-blind study of 190 patients (Schmidt etal 2000).

Commission E supports the use of hawthorn leaf and flower to treat decreased cardiac output (NYHA class II) (Blumenthal et al 2000).

ARRHYTHMIAS, HYPERTENSION AND ATHEROSCLEROSIS

In addition to treating congestive cardiac failure, hawthorn has traditionally been used to treat arrhythmias, hypertension and atherosclerosis, with some evidence to support these uses, although large controlled clinical studies are required (Petkov 1979).

In one double-blind RCT of 92 subjects aged 40-60 years, a hydro-alcoholic extract of Iranian hawthorn (C. curvisepala Lind) given three times daily was found to produce a significant decrease in both systolic and diastolic blood pressure after 3 months. Antihypertensive activity was also observed in one uncontrolled study that used hawthorn berry tincture (equivalent to 4.3 g/day of berry) (Mills & Bone 2000), whereas three randomised, double-blind, placebo-controlled, clinical trials have shown that a combination of natural D-camphor and an extract from fresh hawthorn berries was effective in treating orthostatic hypotension (Georg Belz & Loew 2003, Hempel et al 2005, Kroll et al 2005).

One study that focused primarily on mild hypertension compared the hypotensive effect of low dose hawthorn extract (500 mg) and magnesium supplements, individually and in combination, to placebo. Walker et al found hawthorn treatment significantly reduced resting diastolic blood pressure at week 10 compared with the other groups. In addition, a trend towards a reduction in anxiety was also observed © 2007 Elsevier Australia

with hawthorn treatment, which is an interesting observation as sedative effects have been observed in animal models.

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