Integrated Traditional Chinese and Western Medicine Diagnosis and Treatment Protocol for Chronic Heart Failure

Abstract

Chronic heart failure is a common end-stage syndrome of the cardiovascular system that seriously impairs patients’ quality of life and increases the social and healthcare burden. At present, integrated traditional Chinese and Western medicine treatment for chronic heart failure continues to evolve; however, there is still a lack of standardized diagnostic and therapeutic protocols that fully reflect regional clinical experience, the characteristics of syndrome differentiation in traditional Chinese medicine, and the advantages of integrated Chinese and Western medicine. Therefore, relying on regional medical resources and a multidisciplinary collaborative platform, this protocol systematically summarizes recent advances in the integrated traditional Chinese and Western medicine diagnosis and treatment of chronic heart failure, and, in conjunction with domestic and international guidelines and expert consensus as well as the clinical experience of regional experts, formulates this protocol for the integrated traditional Chinese and Western medicine diagnosis and treatment of chronic heart failure. The aim is to further standardize clinical practice in the integrated diagnosis and treatment of chronic heart failure, improve the quality of care, and fully leverage the exemplary, radiating, and leading role of regional medical centers.

Graphical abstract

Keywords

chronic heart failure / integrated traditional Chinese and Western medicine / syndrome differentiation and treatment / regional clinical practice

Since the publication of the 2016 Expert Consensus on the Integrated Traditional Chinese and Western Medicine Diagnosis and Treatment of Chronic Heart Failure (HF)[1] and the 2022 Guidelines for the Diagnosis and Treatment of Chronic Heart Failure in Traditional Chinese Medicine (TCM)[2], substantial progress has been made in the fields of integrated traditional Chinese and Western medicine diagnosis and treatment, prevention, and comprehensive management of HF. To further standardize the rational application of TCM in the diagnosis and treatment of chronic HF, this protocol fully incorporates the latest domestic and international research findings, with reference to the 2024 Chinese Guidelines for the Diagnosis and Treatment of Heart Failure[3], the 2022 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline[4], and the 2023 European Society of Cardiology (ESC) Guideline[5]. Integrating clinical practice and expert experience in TCM, and following joint discussions among relevant experts, this revised protocol for the integrated traditional Chinese and Western medicine diagnosis and treatment of chronic HF was drafted under the leadership of the Department of Cardiology, The First People’s Hospital of Yunnan Province.

The quality of the included randomized controlled trials of TCM was assessed using the risk of bias assessment tool from the Cochrane Handbook[6]. The quality of the included systematic reviews of TCM was assessed using AMSTAR 2[7]. The quality of evidence was graded into four levels—high, moderate, low, and very low—in accordance with the GRADE system (Table 1)[8]. During the evidence grading process, five downgrading factors (risk of bias, imprecision, inconsistency, indirectness and publication bias) and three upgrading factors (large magnitude of effect, dose-response relationship, and potential confounding factors) were considered. Based on the GRADE decision table, the secretariat drafted preliminary recommendations, which were then voted on by the consensus panel (Table 2). Following the formation of draft recommendations, the final guideline recommendations were developed through solicitation and revision of opinions from experts in both traditional Chinese and Western medicine. Given the characteristics of TCM clinical practice, randomized controlled trials cannot fully evaluate its clinical efficacy and advantages. For classic formulas or preparations that are widely used in clinical practice and have proven efficacy but lack research evidence, if experts deem it necessary to mention the product in the guidelines, it may be recommended “based solely on expert consensus”.

This update primarily covers the following areas.

1. The classification of HF has been updated with the addition of a new category: HF with improved ejection fraction (HFimpEF), defined as patients with a previous left ventricular ejection fraction (LVEF) ≤ 40% who show a follow-up LVEF > 40% with an absolute increase of ≥ 10%. This emphasizes that even if cardiac function improves, it does not signify a complete recovery. Patients must continue to adhere to guideline-directed medical therapy (GDMT), as the risk of relapse is high following discontinuation of treatment. Concurrently, the previous category ‘HF with intermediate ejection fraction’ has been renamed ‘HF with mildly reduced ejection fraction’ (HFmrEF), corresponding to an LVEF of 41%–49%.

2. Reinforcing the cornerstone status of the ‘new quadruple’ drug regimen: Emphasising the foundational role of the combination of an angiotensin receptor-neuropeptidase inhibitor (ARNI)/angiotensin-converting enzyme inhibitor (ACEI), a beta-blocker, an aldosterone receptor antagonist (MRA), sodium-glucose cotransporter 2 inhibitors (SGLT2i) in the management of chronic HF with reduced ejection fraction (HFrEF). The treatment concept has shifted from the “golden triangle” to early multi-pathway combination therapy. Based on the latest evidence-based data, treatment recommendations for patients with chronic HFmrEF and chronic HF with preserved ejection fraction (HFpEF) have been updated, particularly regarding the therapeutic value of SGLT2i in chronic HF across all ejection fraction categories.

3. The staging of HF has been updated to place greater emphasis on prevention. Stage A (at risk of HF) and Stage B (pre-HF) have been separately defined, aiming to shift the intervention to an earlier stage.

4. The TCM diagnosis and treatment guidelines has standardized the key links in the diagnosis and management of chronic HF. It explicitly classifies chronic HF into six syndrome types: Qi deficiency with blood stasis, Yin deficiency with blood stasis, Yang deficiency with blood stasis, insufficient spleen Yang, Yang deficiency with water flooding, and Yang collapse with dyspnea and desertion, and summarizes corresponding therapeutic regimens for each type.

5. Based on experts’ clinical experience, this protocol for the integrated traditional Chinese and Western medicine diagnosis and treatment of chronic HF standardizes the key aspects of diagnosis and treatment. It explicitly classifies chronic HF into six syndrome patterns: qi deficiency with blood stasis, yin deficiency with blood stasis, yang deficiency with blood stasis, spleen yang deficiency, yang deficiency with water retention, and yang collapse with dyspnea. Corresponding treatment regimens for each syndrome pattern are also summarized.

Introduction

Heart failure (HF) refers to a complex clinical syndrome caused by abnormal structural and/or functional changes in the heart resulting from various causes, leading to impaired ventricular systolic and/or diastolic function. It is primarily characterized by dyspnea, fatigue and fluid retention (pulmonary congestion, systemic venous congestion and peripheral edema). Common causes include conditions that increase the workload on the heart, such as myocardial infarction leading to loss of cardiac muscle mass or hypertension resulting in pressure overload[9]. Traditional Chinese medicine (TCM) defines it as ‘heart-water syndrome’, referring to a condition characterized primarily by fatigue, palpitations, shortness of breath and oedema of the limbs. It represents the end-stage condition of various chronic cardiac diseases that recur repeatedly, persist without recovery, and progressively worsen over time.

Based on differences in left ventricular ejection fraction (LVEF) and changes following treatment, it is classified into HF with reduced ejection fraction (HFrEF), HF with improved ejection fraction (HFimpEF), HF with mildly reduced ejection fraction (HFmrEF) and HF with preserved ejection fraction (HFpEF). Studies indicate that patients with LVEF in the 41%–49% range may benefit from treatment for HFrEF[10,11]. Such evidence supports renaming “HF with mid-range ejection fraction” to “HF with mildly reduced ejection fraction (HFmrEF)”[12]. Furthermore, given that an improvement in LVEF does not imply complete recovery from myocardial damage or a return to normal left ventricular function, HFimpEF is defined as a subgroup of HFrEF, characterized by a baseline LVEF ≤ 40% and a follow-up LVEF > 40% with an increase of ≥ 10% from baseline[4].

HF is classified into four stages based on disease progression[4]: Stage A: Patients at risk of HF (e.g., those with hypertension, diabetes, obesity, metabolic syndrome, or a family history of cardiomyopathy, or those who have been exposed to cardiotoxic drugs such as chemotherapy), but who do not yet have structural cardiac changes or abnormal cardiac biomarkers; Stage B: Pre-HF (patients with structural heart disease or abnormal cardiac biomarkers, but without symptoms of HF); Stage C: Symptomatic HF (patients with structural heart disease who have current or past symptoms of HF), Stage D: End-stage HF (patients who experience marked symptoms of HF during daily activities and who, despite receiving optimal drug therapy in accordance with guidelines, frequently require repeated hospitalization). The integrated traditional Chinese and Western medicine strategy for the diagnosis, treatment, and management of chronic HF in this protocol is shown in Figure 1.

Diagnosis and assessment of heart failure

Clinical manifestations

The clinical manifestations of HF vary significantly among individuals depending on the patient’s compensatory status and the affected ventricle. Patients with adequate compensation may present with no obvious symptoms or signs. The main clinical manifestations include the following aspects:

(1) Major symptoms: dyspnea, reduced exercise tolerance, paroxysmal nocturnal dyspnea, fatigue and ankle oedema, etc.

(2) Atypical symptoms: nocturnal cough, loss of appetite, depression, palpitations, and dizziness, etc.

(3) Specific physical signs: jugular vein distension, positive hepatojugular reflux, gallop rhythm, displacement of the apical impulse to the left or lower left, and enlarged cardiac border.

(4) Non-specific physical signs: progressive weight gain, peripheral oedema, wet rales in the lungs, and sinus tachycardia.

Routine examinations

(1) Electrocardiogram (ECG): An ECG is recommended for all patients with HF or suspected HF to determine the heart rhythm, heart rate, morphology and duration of the QRS complex, and to identify the presence of frequent atrial or ventricular premature beats, atrial fibrillation (AF), left ventricular hypertrophy, and other abnormalities.

(2) Chest Imaging: For patients with suspected or acute HF, chest imaging should be performed to identify or rule out pulmonary disease and other causes of dyspnea, whilst assessing for signs of pulmonary congestion/oedema and cardiac enlargement. It should be noted that normal chest imaging findings do not completely rule out a diagnosis of HF.

(3) Blood and urine tests: All patients with suspected HF should undergo the following tests: complete blood count, urinalysis, serum sodium, serum potassium, blood urea nitrogen, creatinine or estimated eGFR, liver function tests, bilirubin, ferritin, transferrin saturation; as well as fasting blood glucose, glycated haemoglobin, lipid profile and thyroid-stimulating hormone levels.

(4) Biomarkers: ① Plasma natriuretic peptides: Elevated plasma natriuretic peptide levels [e.g., BNP or NT-proBNP] may support the diagnosis of HF. When BNP is below 35 ng/L or NT-proBNP is below 125 ng/L, HF can usually be ruled out. It is recommended that plasma natriuretic peptides be routinely used for the screening, diagnosis, differential diagnosis, assessment of disease severity, and prognosis of HF. Measuring natriuretic peptide levels prior to discharge helps predict the risk of cardiovascular events following discharge. ② cTn: Suitable for determining the aetiology and assessing the prognosis of patients with acute HF. In patients with severe HF, cTn levels may be elevated due to local ischaemic damage caused by an imbalance between myocardial oxygen supply and demand; patients with elevated cTn levels have a higher risk of mortality. ③ Other markers: These include indicators of myocardial fibrosis, inflammation and oxidative stress, such as sST2, Gal-3 and GDF-15, which also aid in risk stratification and prognostic assessment in patients with HF.

(5) Transthoracic echocardiography: As the method of choice for assessing cardiac structure and function, it provides detailed information on atrial and ventricular volumes, concentric or eccentric left ventricular hypertrophy, regional ventricular wall motion abnormalities (which may indicate underlying coronary artery disease, Takotsubo syndrome or myocarditis), left and right ventricular systolic and diastolic function, ventricular wall thickness, valve function, and pulmonary arterial hypertension.

Special examinations

(1) Cardiovascular Magnetic Resonance (CMR): CMR is the optimal alternative imaging modality when echocardiographic image quality is suboptimal. For patients with dilated cardiomyopathy, if the diagnosis cannot be confirmed by clinical and other imaging examinations, late gadolinium enhancement (LGE) technique should be used to differentiate ischemic from non-ischemic myocardial injury. CMR is recommended for the assessment of myocardial tissue characteristics in patients with suspected myocarditis, amyloidosis, sarcoidosis, Chagas disease, Fabry disease, left ventricular noncompaction, and hemochromatosis.

(2) Coronary angiography: This is indicated for patients with HF who continue to experience angina despite medical treatment, who have concomitant symptomatic ventricular arrhythmias, or who possess risk factors for coronary artery disease and for whom non-invasive tests suggest myocardial ischaemia.

(3) Coronary CTA: Coronary CTA may be considered to rule out coronary artery stenosis in HF patients with low-to-moderate suspicion of coronary artery disease or inconclusive myocardial ischemia on stress testing.

(4) Nuclear imaging techniques: When echocardiography fails to establish a definitive diagnosis, radionuclide ventriculography can be used to assess left ventricular volume and LVEF. Technetium-labeled bisphosphonate scintigraphy has high diagnostic efficacy for transthyretin cardiac amyloidosis. In HF patients with coronary artery disease, nuclear myocardial perfusion/metabolism imaging can be used to evaluate myocardial ischemia and viability before revascularization.

(5) Cardiopulmonary exercise testing (CPET): Provides quantitative assessment of exercise capacity. It is indicated for clinical evaluation of patients undergoing heart transplantation or mechanical circulatory support (MCS), optimization of exercise prescriptions, and differential diagnosis of unexplained dyspnea.

(6) Six-minute walk test: Used to assess exercise tolerance. A walking distance of < 150 metres indicates severe HF, 150–450 metres indicates moderate HF, and > 450 metres indicates mild HF.

(7) Invasive haemodynamic monitoring: Right heart catheterisation and pulmonary artery catheterisation are indicated for: ① Preoperative assessment prior to heart transplantation or MCS; ② Pressure grading and assessment of reversibility prior to intervention in patients with echocardiographically suggested pulmonary hypertension; ③ Diagnosis of suspected pericardial constriction, restrictive cardiomyopathy, congenital heart disease, or high-output HF; ④ Treatment plan adjustment for patients with persistent severe symptoms despite standard therapy or those with unclear haemodynamic status; ⑤ Diagnosis of HFpEF.

(8) Endomyocardial biopsy: Recommended only for patients with rapidly progressive HF who have failed standard therapy, are clinically suspected of having a treatable specific aetiology, and require biopsy for definitive diagnosis.

(9) Genetic testing: Genetic testing and genetic counselling are recommended for patients with hypertrophic cardiomyopathy, idiopathic dilated cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy. Genetic testing may also be considered for restrictive cardiomyopathy and isolated non-compaction cardiomyopathy.

(10) Quality of life assessment: Psychological scales are used to quantitatively analyse mental health, physical function and social dimensions.

Commonly used general-purpose scales include the 36-item Short Form Health Survey (SF-36), the WHO Quality of Life Index and the European Quality of Life Questionnaire (EQ-5D); HF-specific scales recommended include the Minnesota HF Quality of Life Questionnaire (MLHFQ) and the Kansas City Cardiomyopathy Quality of Life Questionnaire (KCCQ).

Traditional Chinese medicine differentiation

Basic syndromes

(1) Chief manifestations include chest distress, shortness of breath, wheezing, palpitations and oedema.

(2) Early manifestations include shortness of breath and palpitations following exertion, or sudden nocturnal wheezing and coughing that is relieved by sitting upright. As the condition progresses, palpitations occur frequently, wheezing is triggered by movement, or the patient breathes more easily whilst sitting upright and is unable to lie flat. Oedema is most severe in the lower limbs, and in severe cases may affect the whole body, often accompanied by fatigue, lethargy, and abdominal distension.

Diagnostic criteria for syndromes

(1) Qi deficiency with blood stasis syndrome

Main symptoms: Chest distress, shortness of breath, fatigue.

Secondary symptoms: Lethargy and reluctance to speak, easy fatigue on exertion, spontaneous sweating, low voice, and a dark purple complexion or lips.

Tongue and Pulse: Purple-dark tongue (with ecchymosis, petechiae, or tortuous and bluish sublingual collaterals), white tongue coating, deep, thready or forceless pulse.

(2) Yin deficiency with blood stasis syndrome

Main Symptoms: Chest distress, palpitations, dry mouth.

Secondary symptoms: Thirst, dry throat, spontaneous or night sweats, heat in the palms and soles, and a dark purple complexion or lips.

Tongue and Pulse: Dark red or dark purple tongue body (or with ecchymoses, petechiae, or tortuous, cyanotic sublingual veins), thin tongue body, scant or no coating, or peeling coating, or fissures; pulse fine, rapid, weak, or intermittent.

(3) Yang deficiency with blood stasis syndrome

Main symptoms: Chest distress, fatigue, aversion to cold.

Secondary symptoms: Preference for warmth; sensation of cold in the epigastrium, abdomen, lower back, or limbs; cold sweats; dark purple complexion or lips.

Tongue and pulse: Dark purple tongue (or with ecchymoses, petechiae, or tortuous, cyanotic sublingual veins); swollen tongue, or with tooth marks; pulse fine, deep, slow and weak.

(4) Deficiency of spleen yang

Main symptoms: Abdominal distension with poor appetite, aversion to cold with cold limbs, oedema, particularly severe swelling below the waist.

Secondary Symptoms: Cold hands and feet, no thirst, distension and fullness in the epigastrium and abdomen, loose stools, scanty urine.

Tongue and Pulse: Pale or pale and tender tongue, white and greasy coating, deep, slow and taut pulse.

(5) Yang deficiency with fluid retention syndrome

Main symptoms: Shortness of breath, palpitations, oedema, phlegm rising to the throat, or expectoration of pink, frothy sputum.

Secondary Symptoms: Cyanosis of the lips, sweating with cold limbs, restlessness and agitation.

Tongue and Pulse: Pale-dark tongue body, white, watery and slippery coating, fine and rapid pulse.

(6) Yang deficiency with respiratory collapse syndrome

Main symptoms: Shortness of breath preventing lying down; cold and numb limbs.

Secondary symptoms: Restlessness; oily sweat; scanty urine; limb oedema.

Tongue and pulse: Pale and dark tongue with a white coating; pulse faint and fine, almost imperceptible, or rapid and weak.

The above syndromes may appear alone or in combination. Clinical differentiation should be performed according to the specific condition. Generally speaking, qi deficiency with blood stasis syndrome and yin deficiency with blood stasis syndrome are mostly seen in the stable stage of cardiac function class Ⅱ–Ⅲ; yang deficiency with water flooding syndrome is commonly observed in acute exacerbation of cardiac function class Ⅲ–Ⅳ; and yang collapse with dyspnea and desertion syndrome represents a critical manifestation in the end-stage. The syndromes of this disease change dynamically, so treatment should be adjusted in accordance with syndrome evolution.

Treatment of chronic heart failure

General treatment

Sodium and fluid intake

Patients with NYHA Class Ⅲ–Ⅳ HF should restrict sodium intake (< 3 g/day) to control symptoms and signs of congestion. Routine sodium restriction is not required in patients with mild or stable HF. In cases of significant volume overload, fluid intake should be restricted to 1.5–2.0 L/day. Routine fluid restriction has not been shown to be beneficial in patients with mild to moderate HF.

Dietary management

Patients with HF should follow a low-fat diet and strictly abstain from smoking and limit alcohol consumption. Patients with alcoholic cardiomyopathy must abstain from alcohol. Obese patients require weight reduction, whilst those with significant weight loss should receive nutritional support therapy.

Physical activity

Patients with decompensated HF require bed rest and passive exercise to prevent deep vein thrombosis. Once clinical condition improves, patients are encouraged to engage in moderate, regular physical activity. Patients classified as NYHA Class Ⅱ–Ⅲ should undertake rehabilitation exercises under the guidance of rehabilitation specialists. A meta-analysis indicates that the Eight Brocades[13] and Tai Chi[14,15] can improve cardiac function in patients with HF (moderate-quality evidence).

Psychosocial intervention

Depression, anxiety and feelings of loneliness can exacerbate symptoms and affect the quality of life of patients with HF. Psychosocial interventions include counselling, psychotherapy and pharmacotherapy.

Infection prevention

Patients with HF should receive pneumonia, influenza and COVID-19 vaccinations to prevent infection.

Traditional Chinese medicine treatment

Syndrome differentiation and treatment

(1) Qi deficiency with blood stasis syndrome

Treatment Principle: Tonify qi and harmonise the middle jiao; invigorate blood and resolve stasis.

Recommended Formula 1: Astragali Radix (Huang Qi) 30 g, Ginseng Radix et Rhizoma (Ren Shen) 15 g (decocted separately), Atractylodis Macrocephalae Rhizoma (Bai Zhu) 15 g, Poria cocos (Schw.) Wolf (Fu Ling) 15 g, Angelicae Sinensis Radix (Dang Gui) 15 g, Chuanxiong Rhizoma (Chuan Xiong) 9 g, Paeoniae Radix Alba (Bai Shao) 15 g, Rehmanniae Radix (Sheng Di Huang) 9 g, Persicae Semen (Tao Ren) 6 g, Carthami Flos (Hong Hua) 6 g, Glycyrrhizae Radix et Rhizoma Praeparata cum Melle (Zhi Gan Cao) 6 g, Zingiberis Rhizoma (Gan Jiang) 6 g, and Jujubae Fructus (Da Zao) 9 g.

Modifications: If there is fear of cold and cold limbs, add Aconiti Lateralis Radix Praeparata (Zhi Fu Zi, decocted first) and Cinnamomi Cortex (Rou Gui, added later). If there is edema and difficult urination, add Alismatis Rhizoma (Ze Xie) and Plantaginis Semen (Che Qian Zi). If there is obvious phlegm-dampness obstruction, add Trichosanthis Fructus (Gua Lou) 15 g, Pinelliae Rhizoma (Ban Xia) 9 g, and Allii Macrostemonis Bulbus (Xie Bai) 10 g.

Recommended Formula 2: Modified Bu Yang Huan Wu Decoction (from Yilin Gaicuo).

Composition: Astragali Radix (Huang Qi) 30 g, Angelicae Sinensis Radix (Dang Gui) 15 g, Paeoniae Radix Rubra (Chi Shao) 12 g, Chuanxiong Rhizoma (Chuan Xiong) 12 g, Persicae Semen (Tao Ren) 12 g, Carthami Flos (Hong Hua) 10 g, Pheretima (Di Long) 10 g, Hirudo (Shui Zhi) 3 g, Glycyrrhizae Radix et Rhizoma Praeparata cum Melle (Zhi Gan Cao) 10 g, Cinnamomi Ramulus (Gui Zhi) 6 g, Poria cocos (Schw.) Wolf(Fu Ling) 15 g, and Plantaginis Semen (Che Qian Zi) 20 g (wrapped for decoction).

Modifications: If blood stasis is severe, add Hirudo (Shui Zhi) and Eupolyphaga Steleophaga (Tu Bie Chong); if qi deficiency is obvious, add Atractylodis Macrocephalae Rhizoma (Bai Zhu), Citri Reticulatae Pericarpium (Chen Pi), and Codonopsis Radix (Dang Shen).

(2) Yin deficiency with blood stasis syndrome

Treatment Principle: Tonify qi and nourish yin; activate blood circulation and resolve stasis.

Recommended Formula: Shengmai San (from Qianjin Yaofang) combined with Xuefu Zhuyu Tang (from Yilin Gaicuo), with modifications.

Composition: Ginseng Radix et Rhizoma (Ren Shen) 15 g (decocted separately), Ophiopogonis Radix (Mai Dong) 12 g, Schisandrae Chinensis Fructus (Wu Wei Zi) 6 g, Persicae Semen (Tao Ren) 6 g, Carthami Flos (Hong Hua) 6 g, Angelicae Sinensis Radix (Dang Gui) 9 g, Rehmanniae Radix (Sheng Di Huang) 9 g, Chuanxiong Rhizoma (Chuan Xiong) 6 g, Paeoniae Radix Rubra (Chi Shao) 6 g, Bupleuri Radix (Chai Hu) 3 g, Aurantii Fructus (Zhi Qiao) 9 g, Platycodonis Radix (Jie Geng) 6 g, Achyranthis Bidentatae Radix (Niu Xi) 9 g, and Glycyrrhizae Radix et Rhizoma Praeparata cum Melle (Zhi Gan Cao) 6 g.

Modifications: If heart qi deficiency is obvious, add Astragali Radix (Huang Qi) and Codonopsis Radix (Dang Shen); if heart yin deficiency is obvious, remove Rehmanniae Radix (Sheng Di Huang), and add Rehmanniae Radix Praeparata (Shu Di Huang), Scrophulariae Radix (Xuan Shen), and Adenophorae Radix (Nan Sha Shen); if blood stasis is obvious, add Corydalis Rhizoma (Yan Hu Suo) and Salviae Miltiorrhizae Radix et Rhizoma (Dan Shen).

(3) Yang deficiency with blood stasis syndrome

Treatment Principle: Warm the yang and tonify qi; invigorate blood and resolve stasis.

Recommended Formula 1: Zhenwu Decoction (from Shanghan Lun) combined with Xuefu Zhuyu Decoction (from Yilin Gaicuo), with modifications.

Composition: Aconiti Lateralis Radix Praeparata (Zhi Fu Zi) 9 g (decocted first), Poria cocos (Schw.) Wolf (Fu Ling) 15 g, Atractylodis Macrocephalae Rhizoma (Bai Zhu) 15 g, Paeoniae Radix Rubra (Chi Shao) 12 g, Zingiberis Rhizoma Recens (Sheng Jiang) 9 g, Persicae Semen (Tao Ren) 6 g, Carthami Flos (Hong Hua) 6 g, Angelicae Sinensis Radix (Dang Gui) 9 g, Rehmanniae Radix (Sheng Di Huang) 9 g, Chuanxiong Rhizoma (Chuan Xiong) 9 g, Paeoniae Radix Rubra (Chi Shao) 6 g, Bupleuri Radix (Chai Hu) 3 g, Aurantii Fructus (Zhi Qiao) 9 g, Platycodonis Radix (Jie Geng) 6 g, Achyranthis Bidentatae Radix (Niu Xi) 9 g, and Glycyrrhizae Radix et Rhizoma Praeparata cum Melle (Zhi Gan Cao) 6 g.

Modifications: If water-dampness is pronounced, add Alismatis Rhizoma (Ze Xie) and Polyporus umbellatus (Pers.) Fries (Zhu Ling); if phlegm-dampness obstructs the collaterals, add Citri Reticulatae Pericarpium (Chen Pi) and Bambusae Caulis in Taenias (Zhu Ru).

Recommended Formula 2: Modified Wuling San (from Shanghan Lun) combined with Guizhi Fuling Wan (from Jingui Yaolue).

Composition: Cinnamomi Ramulus (Gui Zhi) 20 g, Polyporus umbellatus (Pers.) Fries (Zhu Ling) 12 g, Poria cocos (Schw.) Wolf (Fu Ling) 24 g, Alismatis Rhizoma (Ze Xie) 24 g, Atractylodis Macrocephalae Rhizoma (Bai Zhu) 12 g, Moutan Cortex (Mu Dan Pi) 12 g, Persicae Semen (Tao Ren) 12 g, and Paeoniae Radix Alba (Bai Shao) 12 g.

Modifications: If Yang deficiency is pronounced, add Aconiti Lateralis Radix Praeparata (Zhi Fu Zi, decocted first) and Zingiberis Rhizoma (Gan Jiang); if blood stasis is pronounced, add Salviae Miltiorrhizae Radix et Rhizoma (Dan Shen) and Chuanxiong Rhizoma (Chuan Xiong).

Recommended Formula 3: Sini Tang (from Shanghan Lun) combined with Linggui Zhugan Tang (from Shanghan Lun), with modifications.

Composition: Aconiti Lateralis Radix Praeparata (Zhi Fu Zi) 9 g (decocted first), Zingiberis Rhizoma (Gan Jiang) 10 g, Ginseng Radix et Rhizoma (Ren Shen) 9 g (decocted separately), Poria cocos (Schw.) Wolf (Fu Ling) 15 g, Glycyrrhizae Radix et Rhizoma Praeparata cum Melle (Zhi Gan Cao) 10 g, Salviae Miltiorrhizae Radix et Rhizoma (Dan Shen) 15 g, Notoginseng Radix et Rhizoma Powder (San Qi Fen) 3 g, Amomi Fructus (Sha Ren) 6 g (added later), Citri Reticulatae Pericarpium (Chen Pi) 10 g, Lepidii Semen seu Descurainiae Semen (Ting Li Zi) 10 g, and Alismatis Rhizoma (Ze Xie) 10 g.

Modifications: If there is marked dampness, add Polyporus umbellatus (Pers.) Fries (Zhu Ling); if there is marked yang deficiency, add Cinnamomi Ramulus (Gui Zhi).

Recommended Formula 4: Linggui Yixin Formula

As a clinical empirical formula, Linggui Yixin Formula has been used in the integrated traditional Chinese and Western medicine treatment of chronic HF, particularly in patients with HF associated with ischemic heart disease, and has shown certain efficacy in improving clinical symptoms and cardiac function.

Composition: Cinnamomi Ramulus (Gui Zhi) 10 g, Atractylodis Macrocephalae Rhizoma (Bai Zhu) 10 g, Poria cocos (Schw.) Wolf (Fu Ling) 10 g, Zingiberis Rhizoma (Gan Jiang) 9 g, Acanthopanacis Senticosi Radix et Rhizoma seu Caulis (Ci Wu Jia) 10 g, Polygoni Orientalis Fructus (Shui Hong Hua Zi) 15 g, Verbenae Herba (Ma Bian Cao) 6 g, Corni Fructus (Shan Zhu Yu) 9 g, and Glycyrrhizae Radix et Rhizoma Praeparata cum Melle (Zhi Gan Cao) 6 g.

(4) Syndrome of deficient spleen Yang

Treatment Principle: Warm the yang and strengthen the spleen; promote the flow of qi and drain dampness.

Recommended Formula: Modified Shi Pi Yin (from Jisheng Fang).

Composition: Aconiti Lateralis Radix Praeparata (Zhi Fu Zi) 9 g (decocted first), Zingiberis Rhizoma (Gan Jiang) 9 g, Atractylodis Macrocephalae Rhizoma Praeparata cum Tritico Levis (Chao Bai Zhu) 15 g, Poria cocos (Schw.) Wolf (Fu Ling) 15 g, Magnoliae Officinalis Cortex (Hou Po) 12 g, Aucklandiae Radix (Mu Xiang) 9 g, Tsaoko Fructus (Cao Guo) 3 g, Chaenomelis Fructus (Mu Gua) 3 g, Arecae Pericarpium (Da Fu Pi) 6 g, Zingiberis Rhizoma Recens (Sheng Jiang) 6 g, Jujubae Fructus (Da Zao) 6 g, and Glycyrrhizae Radix et Rhizoma Praeparata cum Melle (Zhi Gan Cao) 9 g.

Modifications: If edema is severe, add Alismatis Rhizoma (Ze Xie) and Polyporus umbellatus (Pers.) Fries(Zhu Ling); if qi deficiency is pronounced, add Codonopsis Radix (Dang Shen) and Astragali Radix (Huang Qi); if cold manifestations are significant, add Cinnamomi Cortex (Rou Gui) and Euodiae Fructus (Wu Zhu Yu).

(5) Yang deficiency with fluid retention

Treatment Principle: Warm the yang and promote diuresis; drain the lungs and relieve wheezing.

Recommended Formula: Modified Zhenwu Decoction (from Shanghan Lun) combined with Tingli-Jujube Lung-Draining Decoction (form Jingui Yaolue: Pulse Patterns, Symptoms and Treatment of Water-Qi Disorders).

Composition: Aconiti Lateralis Radix Praeparata (Zhi Fu Zi) 9 g (decocted first), Poria cocos (Schw.) Wolf (Fu Ling) 15 g, Atractylodis Macrocephalae Rhizoma (Bai Zhu) 15 g, Paeoniae Radix Rubra (Chi Shao) 6 g, Zingiberis Rhizoma Recens (Sheng Jiang) 9 g, Lepidii Semen seu Descurainiae Semen (Ting Li Zi) 15 g, Jujubae Fructus (Da Zao) 9 g, and Glycyrrhizae Radix et Rhizoma Praeparata cum Melle (Zhi Gan Cao) 6 g.

Modifications: f there is insufficiency of heart qi with shortness of breath and fatigue, add Astragali Radix (Huang Qi) and Codonopsis Radix (Dang Shen); if there is marked accumulation of water-dampness, add Alismatis Rhizoma (Ze Xie) and Polyporus umbellatus (Pers.) Fries (Zhu Ling).

(6) Yang deficiency with asthma and collapse

Treatment Principle: Restore Yang and preventing Collapse.

Recommended Formula: Shenfu Longmu Decoction (from Formulary) with modifications.

Composition: Ginseng Radix et Rhizoma (Ren Shen) 15 g (decocted separately), Aconiti Lateralis Radix Praeparata (Zhi Fu Zi) 12 g (decocted first), Fossilia Ossis Mastodi Calcinata (Duan Long Gu) 15 g (decocted first), and Ostreae Concha Calcinata (Duan Mu Li) 15 g (decocted first).

Modifications: If there is incessant sweating, add Corni Fructus (Shan Zhu Yu) and Astragali Radix (Huang Qi); if cold limbs are severe, add Zingiberis Rhizoma (Gan Jiang).

Traditional Chinese medicine

(1) Qi-shen Qi-enhancing dropping pills

Efficacy and indications: Tonifies Qi and unblocks the vessels, activates blood circulation and relieves pain. It is indicated for the pattern of Qi deficiency and blood stasis. It is suitable for patients with stable angina pectoris of coronary heart disease and mild to moderate chronic HF presenting with clinical manifestations such as shortness of breath, fatigue, chest tightness, chest pain, palpitations, and spontaneous sweating.

Usage and dosage: Take half an hour after meals. One sachet (0.5 g/sachet) three times daily. A course of treatment lasts 4 weeks, or as directed by a doctor.

Precautions: Use with caution and monitor coagulation function in patients concurrently taking anticoagulants or antiplatelet agents, and in those planning surgery; use with caution in pregnant women; monitor for gastrointestinal reactions following administration.

Results from a prospective, randomised, double-blind, multicentre, placebo-controlled study[16] indicate that the addition of Qi Shen Yi Qi Drops to standard treatment can improve patients’ exercise tolerance, increase 6-minute walk distance (6MWD) and enhance the Minnesota Heart Failure Treatment Score. (High-quality evidence)

(2) Bu Yi Qiang Xin tablets

Efficacy and indications: Tonifies qi and nourishes yin; promotes blood circulation and diuresis. Indicated for conditions characterized by deficiency of both qi and yin, complicated by blood stasis and fluid retention. Suitable for chronic HF patients presenting with symptoms such as palpitations, shortness of breath, lower limb oedema, and fatigue.

Usage and dosage: Oral use. 4 tablets (0.3 g each) per dose, three times daily; a course of treatment lasts 2 weeks.

Precautions: Use with caution in patients taking digitalis preparations or beta-blockers; those with HF caused by acute myocardial infarction or hyperthyroid cardiomyopathy; those with atrioventricular block, bradycardia, hypokalaemia, or hyperthyroidism; those with severe hepatic or renal impairment; and those with a history of allergies.

Multiple randomised controlled trials have shown that adding Bu Yi Qiang Xin Pian to standard HF treatment improves patients’ quality of life, increases exercise tolerance (6MWD), and reduces the rate of rehospitalisation for HF[17–19]. (Moderate-quality evidence)

(3) Qi Li Qiang Xin capsules

Efficacy and indications: Tonifies qi and warms yang, activates blood circulation and unblocks the collaterals, promotes diuresis and reduces edema. It is indicated for the pattern of yang deficiency with blood stasis and fluid retention. It is suitable for symptoms caused by chronic HF such as palpitations and shortness of breath that worsen with movement, inability to lie flat at night, lower limb edema, intolerance to cold, and cold limbs.

Usage and dosage: Oral use. 4 capsules (0.3 g per capsule) three times daily.

Precautions: Use with caution in individuals with a history of allergies or those with yin deficiency and internal heat; In clinical practice, if other medications for HF are currently being taken, they should not be discontinued abruptly.

Results from a multicentre, randomised, double-blind, placebo-controlled trial[20] indicate that the addition of Qi Li Qiang Xin Capsules to standard therapy reduces NT-proBNP levels in patients (NYHA functional class Ⅱ–Ⅳ), significantly improves cardiac function and quality of life, and increases LVEF and 6MWT. An ongoing randomised, double-blind, placebo-controlled, parallel-group, multicentre, event-driven clinical study involving approximately 3080 patients and 620 target events is currently underway, with positive results anticipated. (High-level evidence).

(4) Xinbao pills

Efficacy and indications: Warms and tonifies the heart and kidneys; tonifies qi and assists yang; promotes blood circulation and unblocks the meridians. Indicated for syndromes of yang deficiency with blood stasis. Suitable for symptoms such as palpitations, shortness of breath, aversion to cold with cold extremities, and soreness and weakness in the lower back and knees caused by chronic HF and sick sinus syndrome.

Usage and dosage: Oral use. For chronic HF, the dosage is 120 mg (2 pills), 240 mg (4 pills) or 360 mg (6 pills) per dose, three times daily, depending on heart function class (1, 2 or 3), with a treatment course of 2 months; once heart function has normalised, switch to a maintenance dose of 60–120 mg (1–2 pills). For severe cases of sick sinus syndrome, take 300–600 mg (5–10 tablets) per dose, three times daily, for a treatment course of 3–6 months. For other arrhythmias (premature contractions) and atrial fibrillation, myocardial ischaemia or angina pectoris: 120–240 mg (2–4 tablets) per dose, three times daily; a course of treatment lasts 1–2 months.

Precautions: It is recommended to take after meals; clearly contraindicated for pregnant women and patients with glaucoma; Contraindicated in patients with yin deficiency with internal heat, hyperactive liver yang, or excessive internal phlegm-fire; should not be used concomitantly with Chinese herbal formulations containing Aconite, Pentas, or Cinnabar; use with caution in lactating women, athletes, patients with hepatic insufficiency, those currently taking digitalis preparations, patients with tachycardia, those with a history of allergies, and patients with poorly controlled hypertension.

A systematic review of RCTs in patients with chronic HF (including 5 RCTs with a total of 591 patients) showed[21] that, compared with Western medicine treatment alone, the addition of Xinbao Pills improved patients’ NYHA functional class and 6MWT, increase LVEF and cardiac output, reduce left ventricular end-diastolic dimension (LVEDD) and left ventricular end-systolic dimension (LVESD), and lower NT-proBNP levels. (Moderate-quality evidence)

(5) Shenfu Qiangxin pills

Efficacy and indications: Tonifies qi and assists yang; strengthens the heart and promotes diuresis. Indicated for the syndrome of yang deficiency with fluid retention. Suitable for chronic HF patients presenting with symptoms of heart and kidney yang deficiency, such as palpitations, shortness of breath, oedema of the limbs, difficulty urinating, and aversion to cold with cold limbs.

Usage and dosage: Oral use. 2 pills (3 g per pill) at a time, 2–3 times daily.

Precautions: Contraindicated in pregnancy; a low-salt diet is recommended; as this product has a warming and tonifying nature, it is not suitable for those with yin deficiency and internal heat.

Small-scale clinical studies suggest[22–24] that Shenfu Qiangxin Pills can improve symptoms in patients with HF and increase exercise tolerance. (Moderate-level evidence)

(6) Tongxinluo capsules

Efficacy and indications: Tonifies qi, invigorates blood, unblocks meridians and relieves pain. Indications: Deficiency of both qi and yin, and stasis obstructing the heart meridians. Suitable for patients with coronary heart disease and angina pectoris presenting with chest oppression, stabbing or cramping pain, fixed and unrelenting pain, palpitations and spontaneous sweating.

Usage and dosage: Oral use. 2–4 capsules (0.26 g per capsule) per dose, three times daily.

Precautions: It is recommended to take after meals to minimise gastrointestinal discomfort; contraindicated in patients with haemorrhagic disorders, pregnant women, women during menstruation, and those with stroke of the yin-deficiency with excessive fire pattern; patients experiencing gastric discomfort after taking the medicine should switch to taking it after meals.

In a study involving 1212 patients with carotid atherosclerosis, Tongxinluo Capsules were found to delay the progression of carotid atherosclerosis and reduce the incidence of first major cardiovascular events[25]; In 219 patients undergoing emergency percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction, the addition of Tongxinluo Capsules to standard Western medical treatment reduced myocardial non-reperfusion and infarct size[26] (moderate-quality evidence).

(7) Shexiang Baoxin pill

Efficacy and indications: Aromatic, warming and promoting circulation; tonifies qi and strengthens the heart. Indicated for patterns of qi stagnation and blood stasis. Suitable for patients with angina pectoris due to coronary heart disease, whether in the acute or stable phase, presenting with symptoms such as chest pain, chest tightness and shortness of breath, or fixed pain.

Usage and dosage: Oral use. 1–2 pills (22.5 mg per pill) three times daily; or take as symptoms arise.

Precautions: It is recommended to take after meals. Those with weak spleen and stomach, breastfeeding women, individuals with allergic constitutions, and athletes should use with caution; should not be used concomitantly with Chinese herbal formulations containing Aconite, Pentas, or Cinnabar.

A single-centre, randomised, double-blind, placebo-controlled trial involving 96 patients with chronic ischaemic HF demonstrated that the addition of Musk Heart-Protecting Pills to standard treatment improved cardiac function[27]. A meta-analysis of 18 RCTs involving 532 patients showed[28] that shexiangbaoxin pill combined with trimetazidine was beneficial for improving symptoms in elderly patients with HF secondary to ischaemic cardiomyopathy. A single-center double-blind, randomized controlled trial indicated that Shexiang Baoxin Pill played an active role in sleep quality and QoL of patients with HFpEF[29]. (Moderate-quality evidence)

(8) Qishen capsules

Efficacy and indications: Tonifies qi, promotes blood circulation, resolves blood stasis and relieves pain. Indicated for conditions involving both qi and yin deficiency complicated by blood stasis. Suitable for patients with coronary heart disease and angina pectoris presenting symptoms such as stabbing chest pain, palpitations, shortness of breath, mental fatigue, and spontaneous or night sweats.

Usage and dosage: Take with warm water after meals. 3 capsules (0.3 g each) three times daily. A treatment course lasts 42 days.

Precautions: Use with caution in pregnant women, women during menstruation, and those with a tendency to bleed.

A randomised controlled clinical trial involving 90 patients with chronic congestive HF complicated by arrhythmia demonstrated that the addition of Astragalus and Ginseng Capsules to standard treatment improved left ventricular ejection fraction and BNP levels, whilst reducing mortality and the rate of unresolved arrhythmia[30]. (Moderate-level evidence)

(9) Yixinshu capsules

Efficacy and indications: Tonifies qi and regulates the pulse; promotes blood circulation and removes blood stasis; nourishes yin and generates body fluids. Indicated for the syndrome of deficiency of both qi and yin with blood stasis. Suitable for patients with coronary heart disease, angina pectoris, and chronic HF presenting with palpitations, chest tightness and shortness of breath, chest pain and discomfort, fatigue and weakness, and spontaneous or night sweats.

Usage and dosage: Oral use. 3 capsules (0.4 g per capsule) three times daily.

Precautions: Use with caution in pregnant women; avoid spicy and greasy foods whilst taking this medicine.

A randomised controlled trial involving 120 patients with coronary heart disease complicated by HF demonstrated that standard treatment for chronic HF combined with Yixinshu Capsules can improve cardiac function, exercise capacity, quality of life scores, and ejection fraction[31]. An observational study involving 179 patients with coronary heart disease and chronic HF demonstrated that conventional treatment combined with Yixinshu Capsules improved cardiac function, reduced TCM syndrome scores, and alleviated clinical symptoms[32]. (Moderate-quality evidence).

(10) Xinyuan capsules

Efficacy and indications: Nourishes the kidneys and heart; promotes blood circulation and dispels blood stasis. Indicated for conditions characterised by deficiency of yin in the heart and kidneys, and obstruction of blood flow in the heart. Suitable for patients with coronary heart disease or chronic HF presenting with chest tightness and discomfort, palpitations, restlessness and insomnia, soreness and weakness in the lower back and knees, tinnitus and dizziness.

Usage and dosage: Oral use. 3–4 capsules (0.3 g per capsule) per dose, three times daily.

Precautions: Contraindicated in patients with hepatic insufficiency and pregnant women; monitor liver biochemical parameters during treatment; use with caution in patients with a history of liver disease, children, breastfeeding women and the elderly; avoid concomitant use with other hepatotoxic drugs; not suitable for patients with excessive phlegm-dampness.

A randomized controlled trial involving 80 patients with coronary heart disease and HF demonstrated that conventional treatment combined with Xinyuan Capsules significantly improved patients’ symptoms, left ventricular ejection fraction, left ventricular end-diastolic diameter, 6-minute walk distance, changes in the Minnesota Heart Failure Quality of Life Score, and the readmission rate due to worsening HF in both groups at 3 months post-treatment[33]. (moderate-quality evidence)

(11) Wenxin granules

Efficacy and indications Tonifies qi and nourishes yin; promotes blood circulation and removes blood stasis. Indicated for conditions characterised by deficiency of both qi and yin combined with obstruction of the heart meridians. Suitable for patients with ventricular premature beats or atrial premature beats presenting with palpitations, shortness of breath, fatigue, chest tightness and chest pain.

Usage and dosage: Dissolve in hot water. Take 1 sachet (5 g per sachet) three times daily, or as directed by a doctor.

Precautions: Use with caution during pregnancy; avoid smoking, alcohol and strong tea whilst taking this medicine; should not be used concurrently with medicines containing colchicine; organic causes of arrhythmia should be ruled out before use.

A meta-analysis based on randomised controlled trials demonstrated that standard treatment combined with Wencheng Granules significantly improved left ventricular end-diastolic diameter and 6-minute walk distance[34].

(12) Shensong Yangxin Capsules

Efficacy and indications: Tonifies qi and nourishes yin; invigorates blood and unblocks meridians; clears the heart and calms the mind. Indicated for conditions of deficiency of both qi and yin, and stasis in the heart meridians. Suitable for patients with coronary heart disease and arrhythmias (ventricular premature beats) presenting with palpitations, restlessness, shortness of breath, fatigue, chest tightness, pain, insomnia and frequent dreaming.

Usage and dosage: Oral use. 2–4 capsules (0.4 g per capsule) per dose, three times daily.

Precautions: Some patients may experience abdominal distension whilst taking this medicine; it is recommended to take it after meals.

Multiple randomized controlled trials have shown that Shensong Yangxin Capsules, when used in combination with standard medication for HF, can increase LVEF and CO, significantly improving cardiac function in patients[35–38].

Distinctive treatments in traditional Chinese medicine

(1) Moxibustion

Acupoints: Commonly selected points include Shuidao and Zhongji

Indications: Suitable for all patterns of disease.

Method: Approximately 20–30 minutes per session, once daily. ① Gentle moxibustion: Light one end of a moxa stick, aim it at the acupoint, and hold it 2–3 centimetres above the skin to apply heat; continue until the patient feels a comfortable warmth and the skin turns slightly red. ② Warm Acupuncture: After achieving Qi through acupuncture, insert a small section of moxa stick onto the needle shaft and ignite it, allowing the heat to penetrate deep into the acupoint via the needle. ③ Indirect Moxibustion (e.g., Ginger Moxibustion):

Pierce several holes in a slice of fresh ginger, place it over the acupoint, then place a moxa cone on the ginger slice and ignite it. Apply moxibustion for 5–15 minutes per acupoint. 2–3 times per week. One course of treatment lasts 8 weeks.

Precautions: Absolutely contraindicated for patients with excess heat syndrome or yin deficiency with excessive fire syndrome (manifesting as a flushed face, red eyes, dry mouth and tongue, and heat in the palms and soles); exercise caution when applying moxibustion to the head and face in patients with uncontrolled hypertension; take precautions against burns in patients with reduced skin sensitivity.

(2) Acupoint plaster application

Common formula: Scutellariae Radix (Huang Qin) 10 g, Aucklandiae Radix (Mu Xiang)10 g, Chuanxiong Rhizoma (Chuan Xiong) 10 g, Platycodonis Radix (Jie Geng) 6 g, Arecae Semen (Bing Lang) 10 g, Borneolum Syntheticum (Bing Pian) 1 g, and Rhei Radix et Rhizoma (Da Huang) 10 g.Paeoniae Radix Rubra (Chi Shao) 10 g, Glycyrrhizae Radix et Rhizoma (Gan Cao) 6 g, Curcumae Rhizoma Praeparata cum Aceto (Cu E Zhu) 10 g, Corydalis Rhizoma Praeparata cum Aceto (Cu Yan Hu Suo) 15 g, Angelicae Sinensis Radix (Dang Gui) 10 g, Cinnamomi Cortex (Rou Gui) 10 g, Zingiberis Rhizoma (Gan Jiang) 10 g, Magnoliae Officinalis Cortex (Hou Po) 10 g, Curcumae Rhizoma Praeparata cum Aceto (Cu E Zhu) 10 g, and Toosendan Fructus (Chuan Lian Zi) 10 g. Mix the above herbs with honey before use.Acupoints: Primary points: Xin Shu (BL15), Guan Yuan (CV4); Auxiliary points: ① Qi deficiency: Shui Fen (BL27), Nei Guan (PC6); ② Phlegm-dampness: Fenglong, Feishu; ③ Yang deficiency: Shenshu, Mingmen; ④ Spleen deficiency: Pishu, Zusanli.

Indications: Suitable for all patterns of syndrome.

Method: The patient sits in a seated position. After routine disinfection of the acupoint area, apply the medicated patch to the corresponding acupoints. Remove after 4–12 hours. Treatment course: 7–10 days per course, once a week.

Contraindications: Local skin ulcers or infections at the application site; individuals allergic to the medicinal patch.

(3) Traditional Chinese medicine auricular acupoints

Acupoints: ① Qi deficiency: Heart, Lung, Kidney; ② Phlegm-dampness: Heart, Triple Energiser, Endocrine; ③ Yang deficiency: Heart, Spleen, Triple Energiser; ④ Spleen deficiency: Heart, Spleen, Kidney.

Indications: Suitable for all patterns of syndrome.

Method: Apply Saussurea seeds to a small piece of adhesive tape, then affix to the selected auricular acupoints. Self-administer pressure 3–5 times daily, for 1–2 minutes per acupoint each time, until a sensation of soreness, numbness, distension or pain is felt. Alternate between both ears. Continuous stimulation is possible; replace the patches regularly. One course of treatment lasts 4 weeks constitutes one course of treatment; each course lasts 7–10 days, with treatment administered once a week.

Contraindications: Local skin ulcers or infections at the application site; individuals allergic to the applied medication.

The aforementioned distinctive TCM therapies may be applied at an appropriate time, depending on the patient’s condition, once their vital signs have stabilised. For example, moxibustion and topical applications are more suitable for the stable and recovery phases; during acute exacerbations, they should be used with caution following assessment.

Western medical treatment

Pharmacological treatment

(1) Diuretics

① Loop diuretics: Furosemide 20–80 mg/day, Torasemide 10–40 mg/day, Bumetanide 1–4 mg/day.

② Thiazide diuretics: Hydrochlorothiazide 25–50 mg/day, Metolazone 2.5–10 mg/day, Indapamide 2.5–5 mg/day.

③ Potassium-sparing diuretics: Spironolactone 40–120 mg/day, Amiloride 25–100 mg/day, Amiloride 2.5–5 mg/day.

④ Vasopressin V2 receptor antagonists: tolvaptan 15 mg/day.

Common adverse reactions: electrolyte disturbances (hypokalaemia, hyponatraemia, metabolic alkalosis), hypotension, renal impairment, hyperuricaemia, etc.

Indications: Diuretics are required for all patients with HF who show evidence of fluid retention.

Contraindications: a. Absence of symptoms or signs of fluid retention; b. Known allergy or intolerance to specific diuretics; c. Patients with gout Thiazide diuretics are contraindicated; d. Tolvaptan is contraindicated in cases of hypovolaemic hyponatraemia, in patients with impaired thirst perception or abnormal response to thirst, and in those currently taking potent cytochrome P450 3A4 inhibitors (e.g., itraconazole, clarithromycin); e. Anuria.

(2) RAS inhibitors

① ARNI

Commonly used drug: Sacubitril/valsartan, administered at a dose of 25–100 mg per dose, twice daily.

Common adverse reactions: deterioration of renal function, hyperkalaemia, hypotension, dry cough, angioedema.

Indications: Patients with HFrEF and NYHA functional class Ⅱ/Ⅲ; for patients with HFrEF and NYHA functional class Ⅱ/Ⅲ who remain symptomatic despite treatment with ACEIs/ARBs, ARNI is recommended as an alternative to ACEIs/ARBs.

Contraindications: a. History of angioedema; b. Severe bilateral renal artery stenosis; c. Pregnant or breastfeeding women; d. Severe hepatic impairment (Child-Pugh Class C), biliary cirrhosis and cholestasis; e. Known hypersensitivity to ARBs or ARNIs. Use with caution in the following situations: a. Serum creatinine > 221 μmol/L (2.5 mg/dL) or eGFR < 30 mL/min/1.73 m²; b. Serum potassium > 5.0 mmol/L; c. Symptomatic hypotension or systolic blood pressure < 95 mmHg.

② ACE inhibitors

Commonly used drugs: Captopril 12.5–50 mg, three times daily; Enalapril 2.5–10 mg, twice daily; Perindopril 4–8 mg daily; Ramipril 1.25–10 mg daily; Benazepril 2.5–20 mg daily, etc.

Common adverse reactions: dry, irritating cough, hypotension, worsening renal function, hyperkalaemia and angioedema (allergic reaction).

Indications: Patients with chronic HFrEF classified as NYHA functional class Ⅱ–Ⅳ, with either past or current symptoms.

Contraindications: a. History of ACEI-induced angioedema with laryngeal oedema; b. Pregnant women; c. Bilateral renal artery stenosis.

Use with caution in the following situations: a. Serum creatinine > 221 μmol/L (2.5 mg/dL) or eGFR < 30 mL/min/1.73 m²; b. Serum potassium > 5.0 mmol/L; c. Symptomatic hypotension (systolic blood pressure < 90 mmHg); d. Left ventricular outflow tract obstruction (e.g., aortic valve stenosis, hypertrophic obstructive cardiomyopathy).

③ ARBs

Commonly used drugs: Valsartan 40–320 mg/day, Irbesartan 150–300 mg/day, Olmesartan 20–40 mg/day, Losartan 25–150 mg/day, Candesartan 4–32 mg/day, etc.

Common adverse reactions: hypotension, worsening renal function and hyperkalaemia, etc.; angioedema is occasionally observed.

Indications: In patients with NYHA class Ⅱ–Ⅳ chronic HFrEF with past or current symptoms, ARBs may reduce the incidence of HF and mortality when ARNI or ACEIs are not tolerated; patients already taking ARBs for other indications may continue the medication if HFrEF subsequently develops.

Contraindications: Apart from angioedema, the same as for ACEIs.

(3) Beta-blockers

Commonly used drugs: metoprolol succinate 11.875–95 mg/day, bisoprolol 1.25–10 mg/day, carvedilol 6.25–100 mg/day, metoprolol tartrate 25–200 mg/day.

Common adverse reactions: exacerbation of HF, bradycardia and atrioventricular block, hypotension, rebound syndrome, etc.

Indications: For patients with chronic HFrEF who have had or currently have symptoms, metoprolol succinate, bisoprolol solol or carvedilol to reduce mortality from HF and the risk of hospitalisation, unless contraindicated or intolerable.

Contraindications: Cardiogenic shock, sick sinus syndrome without a pacemaker or second-degree or higher AV block, hypotension with a heart rate than 50 beats per minute, hypotension with systolic blood pressure < 90 mmHg, and acute exacerbation of bronchial asthma.

(4) MRA

Commonly used drugs: spironolactone 10–40 mg/day and eplerenone 25–50 mg/day.

Common adverse reactions: deterioration of renal function and hyperkalaemia; spironolactone may cause reversible male breast pain or hyperplasia (incidence approximately 10%). Indications: For symptomatic patients with HFrEF, MRA is recommended to reduce HF mortality and hospitalisation rates, provided there are no contraindications or tolerance issues. Contraindications: ① Serum creatinine > 221 μmol/L (2.5 mg/dL) or eGFR < 30 mL/min/1.73 m²; ② Serum potassium > 5.0 mmol/L; ③ Pregnancy.

(5) SGLT2 inhibitors

Commonly used drugs: Dapagliflozin and empagliflozin; the starting and target dose is 10 mg once daily.

Common adverse reactions: a. May increase the risk of genitourinary tract infections. b. Concomitant use with diuretics or RAS inhibitors may lead to excessive diuresis, dehydration, symptomatic hypotension and prerenal renal failure. c. Diabetic ketoacidosis. d. Acute kidney injury and renal impairment. e. Hypoglycaemia. The risk is increased when used in combination with insulin and/or sulphonylureas. f. Necrotising fasciitis of the perineum (Fournier’s gangrene).

Indications: For patients with symptomatic HFrEF, with or without diabetes, SGLT2i (dapagliflozin or empagliflozin) is recommended to reduce the risk of hospitalisation for HF and mortality, unless contraindicated or intolerable.

Contraindications: ① Known drug allergy or history of adverse reactions; ② Pregnant and breastfeeding women; ③ eGFR < 20 mL/min/1.73 m² (empagliflozin) or < 25 mL/min/1.73 m² (dapagliflozin); ④ Hypotension.

(6) sGC stimulators

Commonly used drugs: Vildagliptin 2.5–10 mg/day.

Common adverse reactions: Hypotension; concomitant use with type 5 phosphodiesterase inhibitors or long-acting nitrates should be avoided to prevent an increased risk of hypotension.

Indications: Patients with recent exacerbation of HF, NYHA class Ⅱ–Ⅳ HF and LVEF < 45%; early addition to standard therapy. Its addition may also be considered in patients with NYHA Class Ⅱ–Ⅳ and LVEF < 45% to reduce the risk of cardiovascular death and hospitalisation for HF.

Contraindications: ① Patients currently receiving other sGC stimulators; ② Pregnant women; ③ eGFR < 15 mL/min/1.73 m²; ④ Hypotension.

(7) Ivabradine

Dosage: 5–15 mg/day; the dose should be titrated gradually to achieve a target heart rate of 60 beats per minute. The starting dose should be reduced in elderly patients or those with intraventricular conduction block.

Indications: For symptomatic patients with sinus rhythm and HFrEF who meet any of the following criteria: ① Resting heart rate remains ≥ 70 beats per minute despite β-blockers being administered at the maximum tolerated dose; ② Resting heart rate ≥ 70 beats per minute and contraindications to or intolerance of β-blockers are present.

Contraindications: a. Sick sinus syndrome, second-degree or higher atrioventricular block, resting heart rate < 60 beats per minute; b. Hypotension; c. Acute decompensated HF; d. Severe hepatic impairment; e. Atrial fibrillation/flutter; f. Dependence on atrial pacing; g. History of drug allergy or adverse reactions; h. Pregnancy and lactation.

(8) Digitalis preparations

Commonly used drugs: Digoxin (oral formulation) 0.125–0.25 mg/day; for the elderly, patients with renal impairment or those of low body weight, 0.125 mg once daily or every other day may be used; Digoxin (oral formulation) 0.125–0.25 mg/day; for the elderly, those with renal impairment or low body weight, 0.125 mg once daily or every other day may be used; Digitoxin (intravenous formulation) initial dose 0.4–0.6 mg, followed by 0.2–0.4 mg every 2–4 hours, total daily dose 1–1.6 mg; and digitoxin K (intravenous formulation) initial dose 0.125–0.25 mg; repeat 0.125–0.25 mg as required after 2 hours; total daily dose 0.25–0.5 mg.

Common adverse reactions: a. Arrhythmias (ventricular premature beats are most common; atrial tachyarrhythmias with conduction block are characteristic of toxicity); b. Gastrointestinal reactions; c. Neuropsychiatric symptoms (visual disturbances, disorientation).

Indications: Suitable for patients with HFrEF who remain symptomatic despite adequate treatment with diuretics, RAS inhibitors, β-blockers, SGLT2 inhibitors and MRA.

Contraindications: a. Sick sinus syndrome, second-degree or higher atrioventricular block; b. Acute myocardial infarction (< 24 hours), particularly with progressive myocardial ischaemia; c. Wolff-Parkinson-White syndrome complicated by atrial fibrillation/flutter; d. hypertrophic obstructive cardiomyopathy.

(9) Other medications

① Energy metabolism agents: Trimetazidine 20 mg per dose, three times daily; Coenzyme Q10 tablets 10 mg per dose, three times daily; L-carnitine 1–3 g/day, creatine phosphate 1–2 g/day, etc., may improve symptoms, cardiac function and quality of life; however, their impact on long-term prognosis requires further investigation.

② ω-3 polyunsaturated fatty acids: Supplementation with ω-3 PUFAs in patients with NYHA Class Ⅱ–Ⅳ may help reduce mortality and cardiovascular readmission rates.

③ Potassium-binding agents: In cases of hyperkalaemia (serum potassium ≥ 5.5 mmol/L) following the use of RAS inhibitors (RASIs) or mineralocorticoid receptor antagonists (MRAs), sodium zirconium silicate may be used for long-term maintenance therapy; however, its role in improving the prognosis of HF patients remains unclear.

Other treatments

(1) Device Therapy

① CRT: Improves HF symptoms by correcting cardiac dyssynchrony

Indications: CRT is recommended for patients with HF who, after at least 3 months of optimised medical therapy, still present with the following conditions, to improve symptoms and reduce mortality.

a. Patients with symptomatic HF presenting with sinus rhythm, QRS duration ≥ 120 ms, left bundle branch block (LBBB), and LVEF ≤ 35%; b. Patients with symptomatic HF presenting with sinus rhythm, QRS duration ≥ 130 ms, non-LBBB, and LVEF ≤ 35%; c. Patients with HFrEF requiring a high proportion (40%) of ventricular pacing; d. For patients with atrial fibrillation and LVEF ≤ 35% where ventricular rate control is difficult, atrioventricular node ablation may be performed following biventricular pacing; e. Patients with HFrEF and an LVEF ≤ 35% who have an implanted pacemaker or ICD; if cardiac function deteriorates and is accompanied by a high proportion (40%) of right ventricular pacing, upgrading to biventricular pacing may be considered.

② ICD: For primary or secondary prevention of sudden cardiac death in patients with HF

Indications: Secondary prevention is indicated for patients with resolved haemodynamically unstable ventricular arrhythmias, no irreversible triggers, a life expectancy of > 1 year, and good functional status. Primary prevention is indicated for: a. Patients with ischaemic heart disease who, ≥ 40 days after myocardial infarction or ≥ 90 days after revascularisation, still have an LVEF ≤ 35% and NYHA class Ⅱ or Ⅲ, and a life expectancy of > 1 year, implantation of an ICD is recommended to reduce sudden cardiac death and all-cause mortality; if LVEF ≤ 30% is accompanied by NYHA class I HF, implantation of an ICD is also recommended to reduce sudden cardiac death and all-cause mortality.

b. In patients with non-ischaemic HF, following ≥ 3 months of optimised medical therapy, if the expected survival is > 1 year and LVEF is ≤ 35% with NYHA class Ⅱ or Ⅲ HF, ICD implantation may be considered to reduce sudden cardiac death and all-cause mortality; if LVEF is ≤ 35% with NYHA class I HF, ICD implantation may also be considered. c. ICD implantation is recommended for non-hospitalised patients with NYHA Class Ⅳ HF who are awaiting heart transplantation or receiving LVAD support.

③ CCM: Used to enhance myocardial contractility and improve HF symptoms

Indications: Multiple RCTs have demonstrated that CCM can safely improve exercise tolerance and quality of life in HF patients with LVEF between 25% and 45% and narrow QRS (< 130 ms) exercise tolerance and quality of life. Therefore, CCM may be considered for patients with chronic HF who have an LVEF of 25%–45%, NYHA Class Ⅲ, QRS < 130 ms (and who do not meet the criteria for CRT), and who have failed medical therapy.

(2) Ultrafiltration therapy

Indications: ① Patients with HF who are resistant to diuretics or in whom diuretics provide unsatisfactory relief of congestive symptoms; ② Patients with HF and marked fluid retention; ③ Patients whose HF symptoms have recently worsened due to a significant increase in fluid load.

(3) Renal replacement therapy

Renal replacement therapy may be considered in cases of refractory volume overload combined with the following conditions: ① Persistent oliguria following fluid resuscitation; ② Serum potassium > 6.5 mmol/L; ③ pH < 7.2; ④ Serum urea nitrogen > 25 mmol/L and serum creatinine > 300 mmol/L.

Clinical challenges and improvement strategies in the integrated traditional Chinese and western medicine diagnosis and treatment of chronic heart failure

Several practical issues remain to be addressed in the clinical management of chronic HF, especially end-stage HF. First, patients with end-stage HF often present with multiple organ dysfunction. Persistent and progressively worsening symptoms, such as dyspnea, fatigue, and edema, severely impair patients’ ability to perform activities of daily living and reduce their quality of life. Meanwhile, patients are often affected by negative emotions such as anxiety and depression, and family caregivers may have difficulty meeting their complex care needs. During home-based care, changes in the patient’s condition may not be detected in a timely manner, which can easily lead to disease deterioration and repeated hospitalization.

Second, although diuretics are an important therapeutic approach for relieving volume overload, some patients may develop diuretic resistance. Simply increasing the diuretic dose is often of limited efficacy and may increase the risks of electrolyte imbalance and renal dysfunction. Third, HF management emphasizes fluid restriction, whereas traditional Chinese herbal decoctions may, to some extent, increase fluid burden. If herbal prescriptions are not individualized according to the patient’s volume status, regulation of water-fluid metabolism may be adversely affected.

In response to these issues, patient self-management and health education should be further strengthened. Patients should be guided to regularly monitor body weight, blood pressure, heart rate, and symptom changes. Mobile applications, wearable devices, and other digital tools may also be used, when feasible, to support remote follow-up and dynamic management. For patients with end-stage HF, the concept of palliative care should be introduced at an early stage, with emphasis on symptom control, psychological counseling, and family support.

In terms of treatment, the management of diuretic resistance should be optimized through an integrated Chinese-Western collaborative approach. On the one hand, Western medical strategies should be adjusted, including modification of diuretic administration methods, use of combined diuretic therapy, and appropriate application of modern HF medications such as ARNI and SGLT2i. On the other hand, guided by the core pathogenesis theory of TCM, TCM interventions should be applied based on syndrome differentiation, so as to synergistically improve diuretic efficiency, renal perfusion, and overall circulatory status.

At the same time, the principle of “disease-syndrome combination” should be followed to optimize the application forms of Chinese herbal medicine. Concentrated preparations may be selected according to the patient’s volume load status to reduce fluid intake associated with medication. In addition, integrated Chinese and Western medical treatment regimens should be dynamically adjusted according to indicators such as body weight, urine output, degree of edema, and renal function, thereby achieving the comprehensive goals of reducing volume overload, maintaining therapeutic efficacy, and improving quality of life.

Drafting Institutions: The First People’s Hospital of Yunnan Province; Yunnan Provincial Hospital of Traditional Chinese Medicine; Yunnan University of Chinese Medicine

Leads: Zhang Hong (The First People’s Hospital of Yunnan Province); Xiao Hong (Yunnan Provincial Hospital of Traditional Chinese Medicine)

Principal Drafters: Chen Haoqiang (The First People’s Hospital of Yunnan Province); Wang Anzhu (Shandong Provincial Hospital Affiliated to Shandong First Medical University); Xie Yang (Yunnan Fuwai Cardiovascular Hospital); Yang Zheng (The First People’s Hospital of Yunnan Province)

Chief Reviewers: Wu Yongxin (The First People’s Hospital of Yunnan Province); Yang Tonghua (The First People’s Hospital of Yunnan Province); Zhao Yan (The First People’s Hospital of Yunnan Province)

Expert Panel: Bi Binlin (Wenshan People’s Hospital); Cao Yu (The First People’s Hospital of Yunnan Province); Chen Lijuan (Yunnan Provincial Hospital of Traditional Chinese Medicine); Chen Zongning (Lijiang People’s Hospital); Cai Hongyan (The First Affiliated Hospital of Kunming Medical University); Ding Xiaoxue (The First People’s Hospital of Yunnan Province); Gao Lizhen (The First People’s Hospital of Yunnan Province); Gao Juan (The First People’s Hospital of Yunnan Province); Hao Yinglu (Yuxi People’s Hospital); He Xu (Lijiang People’s Hospital); He Ming (The First People’s Hospital of Qujing); Hu Peng (The First People’s Hospital of Yunnan Province); Hu Weiwen (Yunnan Provincial Hospital of Traditional Chinese Medicine); Han Yong (Nujiang Prefecture People’s Hospital); Liang Liwen (The First People’s Hospital of Yunnan Province); Li Xiang (Yunnan Provincial Hospital of Traditional Chinese Medicine); Li Yujin (The First People’s Hospital of Yunnan Province); Liu Shiqi (The First People’s Hospital of Yunnan Province); Liu Lu (Yunnan University of Chinese Medicine); Luan Yunpeng (Yunnan Provincial Hospital of Traditional Chinese Medicine); Ma Chengdong (The First People’s Hospital of Yunnan Province); Su Wenhua (The First People’s Hospital of Yunnan Province); Sha Sha (Dehong Prefecture People’s Hospital); Wang Anzhu (Provincial Hospital Affiliated to Shandong First Medical University); Wang Yajie (The First People’s Hospital of Yunnan Province); Wang Qian (The First People’s Hospital of Yunnan Province); Wu Haiyan (The First People’s Hospital of Yunnan Province); Wu Xinhua (Affiliated Hospital of Dali University); Xia Jie (Yunnan Provincial Hospital of Traditional Chinese Medicine); Yang Haihui (Pu’er People’s Hospital); Yu Hai (Yuxi People’s Hospital); Zhou Xiuli (The First People’s Hospital of Yunnan Province); Zhuang Ke (The First People’s Hospital of Yunnan Province); Zhang Tao (Xingyao Hospital, Kunming First People’s Hospital); Zhang Yunmei (The First People’s Hospital of Yunnan Province); Zhu Tingting (China Academy of Chinese Medical Sciences); Zhu Qianze (The First People’s Hospital of Yunnan Province).

References

[1] Cardiovascular Disease Committee of the Chinese Association of Integrative Medicine, Expert Committee on Cardiovascular Diseases of the Integrative Medicine Physicians Branch of the Chinese Medical Doctor Association. Expert consensus on the diagnosis and treatment of chronic heart failure with integrated traditional Chinese and Western medicine. Chin J Integr Tradit West Med. 2016;36:133-141.

[2] Project Group for the Guidelines on Diagnosis and Treatment of Chronic Heart Failure in Traditional Chinese Medicine, China Association of Chinese Medicine. Guidelines for the diagnosis and treatment of chronic heart failure in traditional Chinese medicine (2022). J Tradit Chin Med. 2023;64(7):743-756.

[3] Chinese Society of Cardiology of the Chinese Medical Association, Cardiovascular Physicians Branch of the Chinese Medical Doctor Association, Heart Failure Committee of the Chinese Medical Doctor Association, Editorial Board of Chinese Journal of Cardiology. Chinese guidelines for the diagnosis and treatment of heart failure 2024. Chin J Cardiol. 2024;52:235-275.

[4] Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-e1032.

[5] Rashed A, Wasef M, Kalra PR. The 2023 ESC heart failure guideline update and its implications for clinical practice. Br J Cardiol. 2024;31(2):023.

[6] Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.

[7] Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358:j4008.

[8] Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924-926.

[9] Shah AM, Mann DL. In search of new therapeutic targets and strategies for heart failure: recent advances in basic science. Lancet. 2011;378(9792):704-712.

[10] Cleland JGF, Bunting KV, Flather MD, et al. Beta-blockers for heart failure with reduced, mid-range, and preserved ejection fraction: an individual patient-level analysis of double-blind randomized trials. Eur Heart J. 2018;39(1):26-35.

[11] Gupta K, Bajaj NS. Angiotensin-Neprilysin inhibition in heart failure with preserved ejection fraction. N Engl J Med. 2020;382(12):1180-1181.

[12] Lam CSP, Voors AA, Piotr P, McMurray JJV, Solomon SD. Time to rename the middle child of heart failure: heart failure with mildly reduced ejection fraction. Eur Heart J. 2020;41(25):2353-2355.

[13] Wang AZ, Ma XC. Meta-analysis of the efficacy of Baduanjin intervention in patients with heart failure. World Chin Med. 2020;15(13):1939-1945,1952.

[14] Pan L, Yan J, Guo Y, Yan J. Effects of Tai Chi training on exercise capacity and quality of life in patients with chronic heart failure: a meta-analysis. Eur J Heart Fail. 2013;15(3):316-323.

[15] Chen YW, Hunt MA, Campbell KL, Peill K, Reid WD. The effect of Tai Chi on four chronic conditions-cancer, osteoarthritis, heart failure and chronic obstructive pulmonary disease: a systematic review and meta-analyses. Br J Sports Med. 2016;50(7):397-407.

[16] Mao J, Zhang J, Lam CSP, et al. Qishen Yiqi dripping pills for chronic ischaemic heart failure: results of the CACT-IHF randomized clinical trial. ESC Heart Fail. 2020;7(6):3881-3890.

[17] Yao Y, Zhang YZ, Li TF. Analysis of the effects of Buyi Qiangxin tablets on chronic heart failure and volume load. Pharmacol Clin Chin Mater Med. 2017;33(3):187-189.

[18] Zhu AY, Zhou XL. Efficacy analysis of Buyi Qiangxin tablets in the treatment of chronic heart failure. Clin Res Pract. 2017;2:113-114.

[19] Yang XR, Wang ZY, Liu SQ, Long XJ, Wang MH. Effects of Buyi Qiangxin tablets on adverse events in patients with chronic heart failure. New J Tradit Chin Med. 2019;51(2):104-106.

[20] Tang WHW, Huang Y. Cardiotonic modulation in heart failure: insights from traditional Chinese medicine. J Am Coll Cardiol. 2013;62(12):1073-1074.

[21] Yu XX, Zhou XS, Wu YH, Ou AH, Ding BH. Systematic review of Xinbao pills in the treatment of chronic heart failure. J Guangzhou Univ Tradit Chin Med. 2019;36(2):153-159.

[22] Wang ZW, Wang HG. Effects of Shenfu Qiangxin pills on cardiac function, brain natriuretic peptide and inflammatory factors in chronic heart failure. Chin J Exp Tradit Med Formulae. 2012;18(22):319-321.

[23] Deng Y, Jiang Y, Qin BY. Regulatory effects of Shenfu Qiangxin pills on neuroendocrine and related factors in chronic heart failure. Chin J Exp Tradit Med Formulae. 2014;20(15):204-207.

[24] Chen SJ, Zhu M, Xu HB, Huang ZQ. Effects of Shenfu Qiangxin pills on angiotensin Ⅱ and brain natriuretic peptide in chronic heart failure. Chin Arch Tradit Chin Med. 2014;32(04):891-892.

[25] Zhang M, Liu Y, Xu M, et al. Carotid artery plaque intervention with Tongxinluo capsule (CAPITAL): a multicenter randomized double-blind parallel-group placebo-controlled study. Sci Rep. 2019;9(1):4545.

[26] Zhang HT, Jia ZH, Zhang J, et al. No-reflow protection and long-term efficacy for acute myocardial infarction with Tongxinluo: a randomized double-blind placebo-controlled multicenter clinical trial (ENLEAT Trial). Chin Med J (Engl). 2010;123(20):2858-2864.

[27] Ding R, Gui YP, Chen JM, Wu ZG. Effects of Shexiang Baoxin pills on cardiac function in patients with chronic ischaemic heart failure. Acad J Second Mil Med Univ. 2013;34(01):37-40.

[28] Wen J, Ma X, Zhang L, et al. Therapeutic efficacy and safety of Shexiang Baoxin Pill combined with trimetazidine in elderly patients with heart failure secondary to ischaemic cardiomyopathy: a systematic review and meta-analysis. Medicine (Baltimore). 2018;97(51):e13580.

[29] Liu SP, Zhou JG, Jin Y, et al. Therapeutic efficacy of Shexiang Baoxin Pill Combined with exercise in patients with heart failure with preserved ejection fraction: a single-center, double-blind, randomized controlled trial. Chin J Integr Med. 2023;29(2):99-107.

[30] Li CX, Dai Z. Clinical study of Qishen capsules combined with western medicine in the treatment of patients with chronic congestive heart failure complicated with arrhythmia. Chin J Civil Health Med. 2015;27(01):99-100.

[31] Wang QL, Zhou P, Zhu YM, et al. Observation on the efficacy of Yixinshu capsules in patients with dilated cardiomyopathy complicated with chronic heart failure. Capital Med. 2013;20(22):41-43.

[32] Song J. Clinical observation of Yixinshu capsules as adjuvant therapy for coronary heart disease complicated with chronic heart failure. Pract Clin J Integr Tradit Chin West Med. 2025;25(19):104-106.

[33] Hou XL, Yang XG, Song XL, et al. Observation on the efficacy of Xinyuan capsules in the treatment of coronary heart disease with heart failure. J Emerg Tradit Chin Med. 2010;19(11):1838,1852.

[34] Tao S, Yu L, Li J, et al. Comparative efficacy of eight oral Chinese patent medicines for dilated cardiomyopathy with heart failure: a Bayesian network meta-analysis. Syst Rev. 2024;13(1):222.

[35] Yang Z, Yu X, Yu ML. Effects of shensongyangxin capsule on heart rate turbulence and heart rate variability in chronic heart failure. Chin Med J (Engl). 2013;126(22):4389-4391.

[36] Hu Q. Effects of Shensong Yangxin capsules on left ventricular function and heart rate variability in patients with heart failure. China Prescr Drug. 2021;19:131-132.

[37] Shi MJ, Wang LL, Liu R, Zhang L. Effect of Shensong Yangxin capsules as adjuvant therapy in chronic heart failure with atrial fibrillation. Mod Diagn Treat. 2025;36:1120-1122.

[38] Lai LJ, Xie YJ. Clinical effects of Shensong Yangxin capsules in patients with chronic heart failure. Pract Clin Med. 2023;24:15-17, 24.

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