Impact of flavan-3-ols on blood pressure and endothelial function in diverse populations: a systematic review and meta-analysis of randomised controlled trials

Vasiliki Lagou; Arno Greyling; Mario Ferruzzi; Simon S Skene; Joy Dubost; Ayse Demirkan; Inga Prokopenko; Julie Shlisky; Ana Rodriguez-Mateos; Christian Heiss

doi:10.1093/eurjpc/zwaf173

Impact of flavan-3-ols on blood pressure and endothelial function in diverse populations: a systematic review and meta-analysis of randomised controlled trials

Vasiliki Lagou, Arno Greyling, Mario Ferruzzi, Simon S Skene, Joy Dubost, Ayse Demirkan, Inga Prokopenko, Julie Shlisky, Ana Rodriguez-Mateos, Christian Heiss

Nutritional Sciences

Research output: Contribution to journal › Article › peer-review

Abstract

BACKGROUND AND AIMS: Flavan-3-ols, found in cocoa, tea, and certain fruits, show promise in improving blood pressure (BP) and vascular function, but are currently not used for cardiovascular prevention. This meta-analysis evaluated the effects of flavan-3-ol-rich interventions on BP and endothelial function.

METHODS: PubMed was searched for randomized controlled trials (RCTs) published 1946-03/2024 on BP and flow-mediated dilation (FMD) after flavan-3-ol-rich food, beverage, or supplement intake. Random-effects meta-analysis of 109 publications including 145 RCTs and 5,205 participants was performed. (PROSPERO:CRD42023454691).

RESULTS: Flavan-3-ol interventions included epicatechin, epigallocatechin-gallate, cocoa products, tea, grape extract, and apples delivering 586 mg (95%CI 510,662) total flavan-3-ols. Interventions decreased office (-2.8 [95%CI -3.9, -1.7]/-2.0 [-2.6, -1.3] mmHg) and 24h-ambulatory BP (-3.7 [-5.8, -1.6]/-2.6 [-4.5, -0.8] mmHg) after chronic repetitive consumption. Effects were larger with elevated and hypertensive baseline BP or categorical hypertension (office: -5.9 [-10.0, -1.8]/-2.7 [-4.4, -1.0] mmHg, 24h-ABP: -6.8 [-16.3,2.8]/-5.1 [-12.5,2.2] mmHg). Meta-regression analysis confirmed that the magnitude of BP lowering was inversely related to baseline BP, but not to proportion of participants with CVD, diabetes mellitus, and study duration across all studies, and was dose-dependently related to epicatechin dose only in cocoa studies. FMD increased after acute (+2.0% [1.6,2.3]) and repetitive (+1.7% [1.3,2.2]) consumption independent of BP. Reported adverse events were minor and low (0.4%). The considerable heterogeneity of effect sizes (I2>50%) between studies was not explained by the investigated factors limiting the strength of evidence to 'moderate'.

CONCLUSIONS: Flavan-3-ol-rich foods considerably reduce elevated BP and improve endothelial function independent of blood pressure supporting their use for cardiovascular prevention.

Original language	English
Journal	European journal of preventive cardiology
DOIs	https://doi.org/10.1093/eurjpc/zwaf173
Publication status	E-pub ahead of print - 24 Mar 2025

Access to Document

10.1093/eurjpc/zwaf173

Cite this

Lagou, V., Greyling, A., Ferruzzi, M., Skene, S. S., Dubost, J., Demirkan, A., Prokopenko, I., Shlisky, J., Rodriguez-Mateos, A., & Heiss, C. (2025). Impact of flavan-3-ols on blood pressure and endothelial function in diverse populations: a systematic review and meta-analysis of randomised controlled trials. European journal of preventive cardiology. Advance online publication. https://doi.org/10.1093/eurjpc/zwaf173

@article{f62fbe2aef8b417db1d37b193ee045d0,

title = "Impact of flavan-3-ols on blood pressure and endothelial function in diverse populations: a systematic review and meta-analysis of randomised controlled trials",

abstract = "BACKGROUND AND AIMS: Flavan-3-ols, found in cocoa, tea, and certain fruits, show promise in improving blood pressure (BP) and vascular function, but are currently not used for cardiovascular prevention. This meta-analysis evaluated the effects of flavan-3-ol-rich interventions on BP and endothelial function.METHODS: PubMed was searched for randomized controlled trials (RCTs) published 1946-03/2024 on BP and flow-mediated dilation (FMD) after flavan-3-ol-rich food, beverage, or supplement intake. Random-effects meta-analysis of 109 publications including 145 RCTs and 5,205 participants was performed. (PROSPERO:CRD42023454691).RESULTS: Flavan-3-ol interventions included epicatechin, epigallocatechin-gallate, cocoa products, tea, grape extract, and apples delivering 586 mg (95%CI 510,662) total flavan-3-ols. Interventions decreased office (-2.8 [95%CI -3.9, -1.7]/-2.0 [-2.6, -1.3] mmHg) and 24h-ambulatory BP (-3.7 [-5.8, -1.6]/-2.6 [-4.5, -0.8] mmHg) after chronic repetitive consumption. Effects were larger with elevated and hypertensive baseline BP or categorical hypertension (office: -5.9 [-10.0, -1.8]/-2.7 [-4.4, -1.0] mmHg, 24h-ABP: -6.8 [-16.3,2.8]/-5.1 [-12.5,2.2] mmHg). Meta-regression analysis confirmed that the magnitude of BP lowering was inversely related to baseline BP, but not to proportion of participants with CVD, diabetes mellitus, and study duration across all studies, and was dose-dependently related to epicatechin dose only in cocoa studies. FMD increased after acute (+2.0% [1.6,2.3]) and repetitive (+1.7% [1.3,2.2]) consumption independent of BP. Reported adverse events were minor and low (0.4%). The considerable heterogeneity of effect sizes (I2>50%) between studies was not explained by the investigated factors limiting the strength of evidence to 'moderate'.CONCLUSIONS: Flavan-3-ol-rich foods considerably reduce elevated BP and improve endothelial function independent of blood pressure supporting their use for cardiovascular prevention.",

author = "Vasiliki Lagou and Arno Greyling and Mario Ferruzzi and Skene, {Simon S} and Joy Dubost and Ayse Demirkan and Inga Prokopenko and Julie Shlisky and Ana Rodriguez-Mateos and Christian Heiss",

note = "{\textcopyright} The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact [email protected] for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact [email protected].",

year = "2025",

month = mar,

day = "24",

doi = "10.1093/eurjpc/zwaf173",

language = "English",

journal = "European journal of preventive cardiology",

issn = "2047-4873",

publisher = "Oxford University Press",

}

Lagou, V, Greyling, A, Ferruzzi, M, Skene, SS, Dubost, J, Demirkan, A, Prokopenko, I, Shlisky, J, Rodriguez-Mateos, A & Heiss, C 2025, 'Impact of flavan-3-ols on blood pressure and endothelial function in diverse populations: a systematic review and meta-analysis of randomised controlled trials', European journal of preventive cardiology. https://doi.org/10.1093/eurjpc/zwaf173

TY - JOUR

T1 - Impact of flavan-3-ols on blood pressure and endothelial function in diverse populations

T2 - a systematic review and meta-analysis of randomised controlled trials

AU - Lagou, Vasiliki

AU - Greyling, Arno

AU - Ferruzzi, Mario

AU - Skene, Simon S

AU - Dubost, Joy

AU - Demirkan, Ayse

AU - Prokopenko, Inga

AU - Shlisky, Julie

AU - Rodriguez-Mateos, Ana

AU - Heiss, Christian

N1 - © The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact [email protected] for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact [email protected].

PY - 2025/3/24

Y1 - 2025/3/24

N2 - BACKGROUND AND AIMS: Flavan-3-ols, found in cocoa, tea, and certain fruits, show promise in improving blood pressure (BP) and vascular function, but are currently not used for cardiovascular prevention. This meta-analysis evaluated the effects of flavan-3-ol-rich interventions on BP and endothelial function.METHODS: PubMed was searched for randomized controlled trials (RCTs) published 1946-03/2024 on BP and flow-mediated dilation (FMD) after flavan-3-ol-rich food, beverage, or supplement intake. Random-effects meta-analysis of 109 publications including 145 RCTs and 5,205 participants was performed. (PROSPERO:CRD42023454691).RESULTS: Flavan-3-ol interventions included epicatechin, epigallocatechin-gallate, cocoa products, tea, grape extract, and apples delivering 586 mg (95%CI 510,662) total flavan-3-ols. Interventions decreased office (-2.8 [95%CI -3.9, -1.7]/-2.0 [-2.6, -1.3] mmHg) and 24h-ambulatory BP (-3.7 [-5.8, -1.6]/-2.6 [-4.5, -0.8] mmHg) after chronic repetitive consumption. Effects were larger with elevated and hypertensive baseline BP or categorical hypertension (office: -5.9 [-10.0, -1.8]/-2.7 [-4.4, -1.0] mmHg, 24h-ABP: -6.8 [-16.3,2.8]/-5.1 [-12.5,2.2] mmHg). Meta-regression analysis confirmed that the magnitude of BP lowering was inversely related to baseline BP, but not to proportion of participants with CVD, diabetes mellitus, and study duration across all studies, and was dose-dependently related to epicatechin dose only in cocoa studies. FMD increased after acute (+2.0% [1.6,2.3]) and repetitive (+1.7% [1.3,2.2]) consumption independent of BP. Reported adverse events were minor and low (0.4%). The considerable heterogeneity of effect sizes (I2>50%) between studies was not explained by the investigated factors limiting the strength of evidence to 'moderate'.CONCLUSIONS: Flavan-3-ol-rich foods considerably reduce elevated BP and improve endothelial function independent of blood pressure supporting their use for cardiovascular prevention.

AB - BACKGROUND AND AIMS: Flavan-3-ols, found in cocoa, tea, and certain fruits, show promise in improving blood pressure (BP) and vascular function, but are currently not used for cardiovascular prevention. This meta-analysis evaluated the effects of flavan-3-ol-rich interventions on BP and endothelial function.METHODS: PubMed was searched for randomized controlled trials (RCTs) published 1946-03/2024 on BP and flow-mediated dilation (FMD) after flavan-3-ol-rich food, beverage, or supplement intake. Random-effects meta-analysis of 109 publications including 145 RCTs and 5,205 participants was performed. (PROSPERO:CRD42023454691).RESULTS: Flavan-3-ol interventions included epicatechin, epigallocatechin-gallate, cocoa products, tea, grape extract, and apples delivering 586 mg (95%CI 510,662) total flavan-3-ols. Interventions decreased office (-2.8 [95%CI -3.9, -1.7]/-2.0 [-2.6, -1.3] mmHg) and 24h-ambulatory BP (-3.7 [-5.8, -1.6]/-2.6 [-4.5, -0.8] mmHg) after chronic repetitive consumption. Effects were larger with elevated and hypertensive baseline BP or categorical hypertension (office: -5.9 [-10.0, -1.8]/-2.7 [-4.4, -1.0] mmHg, 24h-ABP: -6.8 [-16.3,2.8]/-5.1 [-12.5,2.2] mmHg). Meta-regression analysis confirmed that the magnitude of BP lowering was inversely related to baseline BP, but not to proportion of participants with CVD, diabetes mellitus, and study duration across all studies, and was dose-dependently related to epicatechin dose only in cocoa studies. FMD increased after acute (+2.0% [1.6,2.3]) and repetitive (+1.7% [1.3,2.2]) consumption independent of BP. Reported adverse events were minor and low (0.4%). The considerable heterogeneity of effect sizes (I2>50%) between studies was not explained by the investigated factors limiting the strength of evidence to 'moderate'.CONCLUSIONS: Flavan-3-ol-rich foods considerably reduce elevated BP and improve endothelial function independent of blood pressure supporting their use for cardiovascular prevention.

U2 - 10.1093/eurjpc/zwaf173

DO - 10.1093/eurjpc/zwaf173

M3 - Article

C2 - 40126033

SN - 2047-4873

JO - European journal of preventive cardiology

JF - European journal of preventive cardiology

ER -

Impact of flavan-3-ols on blood pressure and endothelial function in diverse populations: a systematic review and meta-analysis of randomised controlled trials

Abstract

Access to Document

Fingerprint

Cite this