A true salve for the heart, spirit and more

Red Sage

Salvia miltirorrhiza Laminaceae

Vivid red roots resembling blood vessels imitate salvia’s excellence as a medicinal for cardiovascular and cerebrovascular health. A relatively obscure herb in ancient Chinese herbalism, it is now one of TCM’s most prominent herbs and a leading medicinal for heart health, tending to this organ on both a physical and emotional level.

  • How does it feel?

    In powdered tea form, Salvia has a reddish-brown hue on account of the primary chemical compounds, tanshinones, that colour the root. It has a strong aroma and a gentle, earthy, slightly bitter taste.

  • What can I use it for?

    Related to but different from common sage, the western culinary and medicinal herb, obtained from Salvia officinalis.

    In modern Chinese herbalism, salvia has several actions but, first and foremost, it is a blood invigorator. Historically, this action has focused on menstrual complaints, for which it is still frequently used, but nowadays it is best known as a herb for heart health. To this end, it is often prescribed for angina pectoris, myocardial infarction or damage, coronary heart disease, hypertension and palpitations.

    Blood stasis, which typically presents with a purple tongue, sharp, fixed pain and an irregular pulse, can occur for a variety of reasons in TCM – cold congealing the blood, stagnant qi failing to ‘lead the blood’ and phlegm obstruction to name a few. Where nourishing, cooling salvia excels is in treating blood that has stagnated against a backdrop of heat which has ‘dried’ the blood and increased its viscosity.

    Salvia is, however, often prescribed in cases of blood stasis deriving from factors other than heat, where blood stasis is a complicating factor, the branch, where the root cause may be phlegm, cold, prolonged illness, trauma etc. Here, it will not be used as a chief herb but added to support a formula that addresses the underlying cause.

    It is used not only for ‘hot’ cardiovascular presentations but a wide variety of conditions where there is concurrent heat and blood stasis. These can include painful periods, absent periods, retained lochia after childbirth, pain conditions (especially of the chest and abdomen), palpable masses, fibroids, cysts, enlarged liver or spleen, liver disease, cerebrovascular disease and certain skin conditions.

    Salvia also acts on the nervous system, cooling and calming the shen (mind/ spirit) where heat has agitated leading to irritability, restlessness, palpitations and insomnia. This application of salvia is especially useful for cases of warm-febrile disease (‘hot’ infectious diseases) that have not been resolved at the acute, superficial stage and penetrated deeper causing more significant heat symptoms and shen disturbance. It also calms the shen in cases of heat derived from deficient yin energy (in particular of the kidney and heart).

    Finally, salvia mildly nourishes the blood while invigorating, its actions often likened to the formula si wu tang (Four Substances Decoction), the chief TCM formula for tonifying and regulating the blood.

  • Into the heart of Red Sage

    Salvia is a powerful vasodilator and anticoagulant as well as an emmenagogue and sedative. It nourishes, moves and cools the blood, breaks up clots, regulates triglycerides and cholesterol and is applicable for most heart conditions, particularly those associated with excessive or deficient heat (4).

    In TCM, this cooling, bitter herb is known as dan shen and classified as a blood-mover with particular benefit to the heart and liver. Its cool nature sets it apart from most TCM blood invigorators which tend to be energetically warm. Salvia’s sedative properties also make it distinct in this category and are perfectly suited to heart conditions which often have an emotional component, be it as a root cause or an accompanying symptom.

    Over the course of the last century, it has become the focus of much research exploring its perceived cardiovascular, circulatory and cerebrovascular benefits, amongst other things, and the leading herb in numerous popular patent Chinese medicines for heart health, notably fu fang dan shen pian (Compound Dan Shen Dripping Pill).

    Tanshinones, diterpene quinines unique to this herb, are one of its main active constituents. Along with salvianolic acid B, they have demonstrated vasodilatory, anticoagulant, anti-platelet aggregation, anti-inflammatory, antipyretic, antibacterial, antioxidant, anti-atherosclerosis, endothelial protective and myocardial protective properties (5,6).

  • Traditional uses

    Salvia, or dan shen, was first recorded around 100CE in the Shennong Bencao Jing (The Divine Farmer’s Materia Medica) as a bitter, cool herb to treat “evil qi in the heart and abdomen, continually gurgle intestines like water running; it also breaks concretions, eliminates conglomerations, relieves vexatious fullness, and boosts the qi” (5).

    Up until the 20th century salvia was used not so much as a blood invigorator but rather for bleeding disorders, in particular menstrual bleeding (5).

  • Traditional actions

    Traditional Chinese Medicine actions:

    • Channels/ organs: Heart, Liver, Pericardium
    • Action: Invigorate the blood

    Western herbal medicine actions:

    • Emmenagogues
    • Sedative
    • Vasodilator

  • What practioners say

    Cardiovascular: salvia relaxes coronary and peripheral blood vessels, inhibits the formation of blood clots and arterial plaque to promote blood circulation and relieve local anemia, and is used widely in Chinese hospitals and clinics to treat angina pectoris, coronary heart disease, atherosclerosis, myocardial infarction, myocardial damage and hypertension. Generally well-tolerated and relatively mild, it may be taken long-term for cardiovascular disease as a preventative, a therapy, an emergency treatment, alongside conventional medicine, post-heart attack recovery and before and after operations. For this, it is used alone or with other blood moving herbs such as Notoginseng (san qi) as in fufang danshen pian (Compound Danshen Dripping Pill), the primary TCM herbal formula for cardiovascular disease (2,7).

    Reproductive: used in cases of irregular menstruation, menstrual pain, postpartum pain and absent periods stemming from blood stasis, often alongside Chinese Angelica (dang gui). Also prescribed in cases of abdominal masses, endometriosis, fibroids and cysts.

    Pain: used for a variety of pain conditions, including musculoskeletal pain, owing to blood stasis which will typically present as fixed and stabbing in nature. Typically combined with other blood movers such as Ligisticum (chuan xiong) or with Santalum (tan xiang) and Cardamon (sha ren) for qi and blood stagnation of the chest, flank, epigastrium and abdomen as in dan shen yin (Salvia Decoction) which with the appropriate presentation may be used for pain associated with angina, hepatitis, pancreatitis, cholecystitis, chronic gastritis, peptic ulcer and period pain (1). It is often combined with Frankincense (ru xiang) for pain and swelling from blood stasis (1).

    Nervous: calms the mind and treats restlessness, irritability, insomnia and palpitations from both deficiency – in particular, heart blood and kidney yin deficiency, where it may be combined with herbs such as Jujube seeds (suan zao ren) and Biota seeds (bai zi ren) – and excess, especially in cases of acute febrile disease where it can cool the blood and will be combined with herbs to purge pathogenic heat. Salvia also has neuroprotective properties and is often used to treat Alzheimer’s disease.

    Liver: salvia is the primary TCM herb for the prevention and treatment of liver damage due to viral hepatitis (5) and is frequently used for liver disease, including alcoholic liver disease and chronic hepatitis, as it accelerates the repair of liver lesions and enriches liver cell nutrition (2). It is also used to treat cases of an enlarged liver (hepatomegaly).

    Cerebrovascular: along with its vascular benefits, salvia is also believed to decrease cerebral oedema, infarct size and neurological deficit (8) and is often used in Chinese hospitals to treat cerebrovascular disease, typically in injection form such as Dan Hong Injection (Salvia, Safflower (hong hua)) and Danshen Chuanxiongqin Injection (Salvia, Ligusticum (chuan xiong)) which are often prescribed for stroke.

    Blood deficiency: In TCM, blood deficiency – sometimes, but not always, equitable to anaemia – can stem from blood stagnation. In such cases, salvia may be used to move the old blood to generate the new.

    Skin: may be used in cases of sores and swellings of the skin such as carbuncles and breast abscesses, with herbs such as Trichosanthes fruit (gua lou).

  • Research

    A 2019 meta-analysis found that the main bioactive ingredients of salvia – tanshinone IIA or sodium tanshinone IIA sulfonate (a water-soluble derivative of tanshinone IIA) or salvianolate – have numerous cardioprotective effects, including antioxidative, inhibition of apoptosis, anti-inflammatory, anti-cardiac fibrosis, anti-cardiac hypertrophy, anticoagulation, anti-AS, vasodilating, reduction of macrophage derived foam cell formation and inhibition of proliferation and migration of vascular smooth muscle cells. In addition to this, some of the clinical studies found that salvia preparations in combination with conventional medicine were more effective at treating some cardiovascular diseases including angina pectoris, myocardial infarction, hypertension, hyperlipidemia, and pulmonary heart diseases (6).

    Tanshinones, specifically, also have proven antibacterial, anti-tumor and neuroprotective properties. Tanshinone I, tanshinone IIA, and cryptotanshinone have been found to display significant neuroprotective effects in various studies (3).

    Salvia’s hepatoprotective properties have been shown to reduce fat accumulation and liver damage, thereby protecting against early stage alcoholic liver disease and significantly decreased hepatic triglyceride contents, liver weights and plasma ALT levels when administered to alcohol-fed mice (9).

    Numerous studies have shown that fu fang dan shen pian (Compound Dan Shen Dripping Pill (CDDP)) – made up of Salvia (dan shen), Notoginseng (san qi) and Borneol (bing pian) –  has many therapeutic actions including pain relief, promoting blood circulation, reducing blood lipids, protecting blood vessels and myocardium and improving heart function (10) and it was the first TCM formulation to successfully complete Phase II clinical trial under the US Food and Drug Administration (FDA)’s Investigational New Drug (IND) application (7).

    The study featured 125 patients with moderate chronic stable angina pectoris over a period of eight weeks. All were taken off their usual medications for angina pectoris (except for on-demand short-acting nitrates and one beta-blocker or calcium channel blocker) and given 0 pills (placebo group), 20 pills twice daily (low dose group) or 30 pills twice daily (high dose group). Total Exercise Duration (TED) was measured after four weeks of treatment and the mean improvement of TED compared to placebo was 20 seconds (low dose group, P = 0.18) and 43 seconds (high dose group, P = 0.005), with no serious adverse drug reactions observed, suggesting that CDDP was effective and safe for the treatment of angina pectoris of CHD (7).

    Another patent medicine, Dan Hong Injection (DHI), made up of Salvia (dan shen) and Safflower (hong hua) is also widely prescribed for stroke and coronary artery disease (11). Its main bioactive ingredients are salvianolic acid B, salvianolic acid A and hydroxysafflor yellow A (12) and research has shown it may ameliorate cerebral ischemia-reperfusion injury, cerebral ischemia damage, myocardial reperfusion injury, myocardial hypertrophy, cardiac dysfunction and cardiac ventricular remodelling (11).

  • Did you know?

    The name Salvia comes from the Latin word salvare, meaning ‘to heal’, and miltiorrhiza from the Greek miltos and rhiza, meaning ‘red lead’ and ‘root’, owing to the crimson colour of the root (2).

Additional information

  • Safety

    Salvia is generally very well tolerated, however, mild side effects such as allergy, stomach upsets, dizziness and reversible thrombocytopenia have been noted. Use with caution in pregnancy, where there is no blood stasis, when using anticoagulant medication and with those prone to bleeding.

  • Interactions

    May interfere with the heart medication digoxin. Incompatible with li lu (Radix et Rhizoma Veratri).

  • Preparation

    Used alone or in a herbal formula in decoction, granule, powder, pill, tablet, soft gel, oral liquid, injection or intravenous drip form. Wine-frying the raw dried herb enhances its blood invigorating properties. Not advised for use in a tincture (1).

  • Dosage

    6-15g raw dried herb, up to 60g if used on its own

  • Plant parts used

    Root and rhizome

  • Constituents

    • Tanshinone I, IIA, IIB
    • Cryptotanshinone
    • Isotanshinone I, II
    • Isocryptotanshinone
    • Militrone
    • Tanshinol I, II
    • Salviol
    • Vit E
  • Habitat

    S. miltiorrhiza grows wild throughout China and Inner Mongolia on sunny mountains, roadsides, fields, forests and along streams preferring moist, sandy soils and is cultivated widely across China (2).

  • Sustainability

    Excessive harvesting of wild dan shen has led it to the brink of extinction. It has, however, been cultivated widely in China since the 1970s, particularly in Shanxi, Sichuan, Hebei, Henan and Shandong provinces (1,2,3).

  • Quality control

    Salvia root is harvested in late Autumn to early Spring while the plant is dormant. The best quality is said to be harvested in the first ten days of November and wild-harvested in Sichuan province (chuan dan shen). The cultivated root, however, is often both larger and considered superior to the wild variety (2). Good quality salvia root is described as coarse and purplish black inside with small white spots (1). Tanshinone IIA, along with salvianolic acid B, are often used as markers of quality (5,6).

  • How to grow

    May be grown from either seeds or root divisions. Seeds may be sown indoors in early spring then transplanted after the last frost and seedlings can be transplanted once 3-5 inches to permanent locations, spaced around one foot apart in April or August. Cold tolerant and likes sandy, moist, but well-drained, soil (2).

  • References

    1. Bensky D, Gamble A. Chinese Herbal Medicine: Materia Medica. 2nd ed. Washington: Eastland Press; 1993.
    2. Foster S, Yue C. Herbal Emissaries: Bringing Chinese Herbs to the West. Vermont: Healing Arts Press; 1992.
    3. Jiang Z et al. Tanshinones, Critical Pharmacological Components in Salvia miltiorrhiza. Frontiers in Pharmacology. 2019. Vol. 10. doi: 10.3389/fphar.2019.00202
    4. Tierra L. Healing with the Herbs of Life. New York: Crossing Press; 2003.  
    5. Dharmananda, S. Salvia and the History of Microcirculation Research in China. Published August 2001. Accessed July 2022. http://www.itmonline.org/arts/salvia.htm
    6. Ren J et al. Salvia miltiorrhizain Treating Cardiovascular Diseases: A Review on Its Pharmacological and Clinical Applications. Front Pharmacol. 2019 Jul 5;10:753. doi: 10.3389/fphar.2019.00753.
    7. Writing Group of Recommendations of Expert Panel from Chinese Geriatrics Society on the Clinical Use of Compound Danshen Dripping Pills. Recommendations on the Clinical Use of Compound Danshen Dripping Pills. Chin Med J (Engl). 2017 Apr 20;130(8):972-978. doi: 10.4103/0366-6999.204106.
    8. Cheng TO. Cardiovascular Effects of Danshen. Int J Cardiol. 2007. doi: 10.1016/j.ijcard.2007.01.004. Epub 2007 Mar 23. PMID: 17363091.
    9. Ding et al. Danshen Protects Against Early-Stage Alcoholic Liver Disease in Mice via Inducing PPARα Activation and Subsequent 4-HNE Degradation. PLoS One. 2017 Oct 11;12(10):e0186357. doi: 10.1371/journal.pone.0186357.
    10. Sun et al. Compound Danshen Dripping Pills in Treating with Coronary Heart Disease. Medicine. 2022. Vol 101. doi: 10.1097/MD.0000000000028927.
    11. Lyu M et al. Network Pharmacology Exploration Reveals Endothelial Inflammation as a Common Mechanism for Stroke and Coronary Artery Disease Treatment of Danhong injection. Sci Rep. 2017 Nov 13;7(1):15427. doi: 10.1038/s41598-017-14692-3.
    12. Feng X et al. Danhong Injection in Cardiovascular and Cerebrovascular Diseases: Pharmacological Actions, Molecular Mechanisms, and Therapeutic Potential. Pharmacological Research. 2019. Volume 139. 2019. doi.org/10.1016/j.phrs.2018.11.006.

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