Enjoy Healthier Veins with Horse Chestnut Extract

Enjoy Healthier Veins with
Horse Chestnut Extract

Solid evidence shows its value in treating a common, potentially deadly affliction
By Dr. Edward R. Rosick

Horse chestnuts (Aesculus hippocastanum)
here are not many of us who wouldn’t like to revisit the carefree days of our youth. Some of my best memories are of long, lazy days that seemed to stretch on forever. In the fall I would collect beautiful, shiny brown horse chestnuts (the seeds of the chestnut tree) when the spiky green fruit capsules fell to the ground and split open. Irresistible, especially to an inquisitive 10-year-old. I would use the chestnuts in arts and crafts projects (e.g., a necklace for my mom, who occasionally wore it at home but, strangely, never when she went out), as slingshot ammo, and as almost indestructible toys for the cat (but not for shooting at cats!).

How astonished I would have been if someone had told me that horse chestnuts could be used as medicine. Yet the fact is that horse chestnut extracts have long been used in traditional medicine for menstrual cramps, arthritis, and weak veins (and for treating cough in horses, which may be the origin of the name). The condition of having weak veins, more properly called chronic venous insufficiency, is a common, yet commonly overlooked, disease that afflicts millions of Americans.

How Does Your Blood Flow?

While medical conditions affecting our arteries, such as atherosclerosis and coronary artery disease, get plenty of attention in both the lay and medical media, problems in our veins are often overlooked. Yet a compromised venous system will lead to health problems that can become serious and, occasionally, as deadly as a heart attack. To see how this can happen, let’s briefly review the human circulatory system.

CVI is characterized by poor venous
drainage of the legs, resulting in
ankle and leg edema, generalized
leg pain, and varicose veins.

The circulatory system has two major parts: arterial (arteries and arterioles) and venous (veins and venules), which are connected by billions of capillaries, with a combined length of about 60,000 miles (yes, 60,000 miles). Arteries deliver oxygenated blood from the heart to all parts of the body (and to the heart muscle itself, via the coronary arteries), and veins deliver oxygen-depleted blood back to the heart and lungs. The flow sequence is: heart–arteries–arterioles–capillaries–venules–veins–heart–lungs–heart–arteries–etc. A complete circuit takes about half a minute.

Repeal the Law of Gravity!

Unlike the arterial system, in which blood is propelled by the forceful, rhythmic contractions of the heart, the force that propels venous blood back to the heart and lungs is generated mainly by muscles that surround the veins. This process is vitally important in the lower parts of the body, especially the legs, where the blood must be pushed uphill against the force of gravity (unless, of course, you’re in the International Space Station!). It is aided by a series of one-way valves in the leg veins that prevent the blood from flowing back down.

As we age, however—especially if we lose muscle mass from not staying fit—the walls of our veins can become weakened, and the valves can fail, leading to a buildup of excess blood in our lower extremities. This pooling of sluggish blood causes increased pressure on the extremely fine, thin-walled capillaries, particularly in the lower legs, ankles, and feet. As the capillaries become distended by the pressure, they become more permeable and begin to leak fluid into the surrounding tissues, which swell as a result. That’s called edema, and it’s a characteristic sign of chronic venous insufficiency.

Chronic Venous Insufficiency Is a Serious Disease

Chronic venous insufficiency (CVI) is characterized by inadequate venous drainage of the lower extremities, resulting in ankle and leg edema, generalized leg pain, and varicose veins, which are unsightly bulges and twists in surface veins caused by the pooling of blood at weak spots. (Hemorrhoids, by the way, are varicose veins.) CVI is unfortunately very common, especially in the elderly, in whom it is estimated to affect 10–15% of men and 20–25% of women.

Although varicose veins in the legs are usually harmless, they signal the presence of CVI, which can lead to serious, and even life-threatening, consequences. In the former category are venous ulcers, which are open sores on the skin of the lower extremities. Over half a million Americans are believed to suffer from these ulcers, which are resistant to treatment and very slow to heal.

An even more severe consequence of CVI is deep-vein thrombosis, the formation of a thrombus, or blood clot, deep inside the leg. Although such thrombi can’t be seen or felt, they can break free and migrate to the victim’s lungs. If that happens, an event called pulmonary embolism can occur, which can cause almost instant death. Because deep-vein thrombosis can be brought on by the unnatural stress of sitting for many hours in a cramped airplane seat, with legs bent, it’s often called the “economy class syndrome.” (See “Flying on Flavonoids Could Save Your Life” in the January 2004 issue.)

Horse Chestnut Can Combat CVI

The standard treatment for CVI in mainstream medicine is the use of compression stockings, which help push the blood in the lower extremities back toward the heart. Although these stockings do help alleviate many of the common symptoms of CVI, they do nothing to correct the underlying problem. Furthermore, they can be uncomfortable to wear (although wearing them on long flights is a good idea for anyone at risk for deep-vein thrombosis)—and patient discomfort often means poor compliance. As with any other medication or treatment plan, if it isn’t used conscientiously, then the problem (in this case, CVI) will persist and probably get worse.

So other than trying to find a “magic bullet” that will turn back the aging clock, what can you do to prevent CVI? First, an active lifestyle that includes daily exercise can help keep your veins as well as your muscles toned and fit. Second, incorporating some safe, natural supplements, such as horse chestnut, into your daily diet can help maintain and even improve venous tone, thus reducing the risk for the complications—from mild to fatal—of CVI. Horse chestnut is widely prescribed in Europe for this condition.

E Pluribus Unum

A recent literature review of a special kind called meta-analysis (see the sidebar on this topic) examined the existing research on the safety and efficacy of horse chestnut seed extract (HCSE) for CVI. The goal was to integrate the results of many individual, carefully selected clinical trials into one unified study—a meta-analysis. Since such a study is by nature far more comprehensive and substantial than any individual trial, a high degree of credibility typically attaches to the results. The results in this case suggested that HCSE should be widely used for CVI.1

Lies, Damned Lies, and Meta-Analysis

With the political season in full swing, the airwaves and newspapers are filled with candidates bloviating on the issue du jour, using masses of seemingly contradictory statistics to back up their questionable claims (OK, lies). Even in the scientific world, statistics can often be bent and twisted to suit the purpose at hand, so it’s a wise person who uses common sense, as well as an understanding of mathematics, to try to penetrate the statistical fog and discern the truth.

Trying to get a better grip on the vast amount of information published in approximately 40,000 scientific journals is a major problem. As research results pile up, it becomes ever more difficult to ascertain the difference between good science and junk science and to integrate the results of the good studies so as to arrive at statistically valid conclusions.

Mathematical techniques that can be used for the statistical synthesis of data from separate but similar (i.e., comparable) studies, leading to a quantitative summary of the pooled results, were developed two centuries ago. Astronomers put these techniques into practice in the mid-nineteenth century, and medical scientists adopted them around the turn of the century. It was not until 1976, though, that this method of truth seeking acquired its present name: meta-analysis.

In a meta-analysis, the reviewers set standards that will tend to minimize factors that could lead to significant errors, such as methodological shortcomings, systematic differences in study characteristics, and effects due to chance. In this way, they can screen out studies that don’t measure up, leaving only the cream of the crop (which is sometimes only a small minority of the existing studies) for the final analysis. Applying powerful mathematical methods to the pooled data from these remaining studies then leads to conclusions that are much more likely to be true than those of any individual study, no matter how well it might have been conducted.

Gotu Kola and Flavonoids vs. CVI

Besides horse chestnuts, nature has provided us with other safe, natural supplements that can help prevent or alleviate chronic venous insufficiency (CVI). The herb gotu kola (Centella asiatica)—and especially an extract of this herb called TTFCA (total triterpenic fraction of Centella asiatica)—has been shown in multiple studies to combat CVI by improving venous tone.1,2 Like horse chestnut seed extract, TTFCA has a very low side-effect profile.

The naturally occurring flavonoids diosmin, hesperidin, and troxerutin are also safe, effective supplements that can be used to prevent and treat CVI. (Flavonoids are plant pigments that give colors to flowers, fruits, and vegetables.) Diosmin and hesperidin in combination are used throughout much of the world as a prescription drug treatment for CVI and related disorders. The standard formulation is called micronized purified flavonoid fraction (MPFF), which consists of 90% diosmin and 10% hesperidin.

A recent review of the safety and efficacy of MPFF concluded that its efficacy in helping to prevent and treat problems in the venous system, specifically CVI and venous ulcers, has been demonstrated in both short- and long-term studies.3 The flavonoids are thought to act in varied ways, such as increasing venous tone, improving lymphatic drainage, and reducing capillary hyperpermeability.

  1. Cesarone MR, Belcaro G, De Sanctis MT, et al. Effects of the total triterpenic fraction of Centella asiatica in venous hypertensive microangiopathy: a prospective, placebo-controlled, randomized trial. Angiology 2001;52 Suppl 2:S15-18.
  2. Incandela L, Cesarone MR, Cacchio M, et al. Total triterpenic fraction of Centella asiatica in chronic venous insufficiency and in high-perfusion microangiopathy. Angiology 2001;52 Suppl 2:S9-13.
  3. Lyseng-Williamson KA, Perry CM. Micronised purified flavonoid fraction: a review of its use in chronic venous insufficiency, venous ulcers, and haemorrhoids. Drugs 2003;63(1):71-100.

The authors identified 28 randomized, controlled trials, and of these, 16 (published between 1976 and 2002) met certain standards of scientific validity that were adopted as inclusion criteria for the meta-analysis. Of the 16 trials, ten were placebo-controlled, five were controlled by comparison with other medications, and one was controlled by comparison with compression stockings and placebo. Thirteen of the trials used an amount of HCSE that was standardized to deliver 100 mg/day of escin (the chemical component of HCSE that is thought to be most active in combating CVI); 2 used 150 mg/day; and 1 used 50 mg/day.

Horse Chestnut Is Effective (and Safe) Against CVI

The principal conclusion reached in the meta-analysis was that HCSE is a safe and effective treatment for a wide variety of CVI-related symptoms, including:

  • Leg pain – Of seven placebo-controlled trials (PCTs) that assessed leg pain, six showed statistically significant reductions with HCSE.
  • Edema – Of six PCTs that assessed edema, four showed statistically significant reductions with HCSE.
  • Pruritus (itching) –This may not sound like much of a complication, but intense itching, or pruritus, can actually be quite painful and lead to skin abrasions that can then progress to infections. Of eight PCTs that assessed pruritus, four showed statistically significant reductions with HCSE.
  • Leg volume – Of six PCTs that assessed leg volume (a measure of excess fluid accumulation), five provided adequate data for analysis, and they showed statistically significant reductions with HCSE.
  • Calf and ankle circumference – Of seven PCTs that assessed calf and ankle circumference (which likewise indicate fluid accumulation), five showed statistically significant reductions at the ankle, and three at the calf, with HCSE.

This solid scientific evidence for the efficacy of HCSE in alleviating the symptoms of CVI is gratifying, of course, but it would be worthless unless there were also evidence of HCSE’s safety—and there is. Of the 13 PCTs that reported on side effects associated with the use of HCSE, four reported no side effects, four reported good tolerability, and five reported only minor side effects, such as stomach upset and headache.

From Childhood Toy to Grownup Medicine

Let’s face it—we’re all getting older. But scientists are busy trying to help us mitigate the effects of aging so that we can age better—and longer—than preceding generations. Their job is to discover knowledge that will be useful to us, and our job is to act on that knowledge so as to maintain our health and vitality for longer than was previously thought possible. That means that we have to live right, so to speak. We now know that one aspect of living right is the judicious use of supplements that can help us minimize or avoid some of the debilitating ailments that were long thought to be an inevitable result of aging.

It seems oddly heartwarming to know that horse chestnuts, those glistening baubles with which Mother Nature delighted us when we were children, can now help us keep our aging veins fit and healthy, thereby slowing down life’s clock a little and giving our inner child more time to play.


  1. Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. John Wiley & Sons, Ltd., Chichester, UK.

Dr. Rosick is an attending physician and clinical assistant professor of medicine at Pennsylvania State University, where he specializes in preventive and alternative medicine. He also holds a master’s degree in healthcare administration.

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