The gut-heart axis in heart failure: from bidirectional pathophysiological mechanisms to integrative therapeutic strategies

Heart failure (HF), as the terminal stage of cardiovascular diseases, involves complex pathophysiological mechanisms that extend beyond the heart itself and involve the interactive regulation of multiple organ systems. The gut-heart axis theory reveals that the gut microbiota, functioning as a micro-organ, plays a core role in the development and progression of HF through bidirectional regulatory mechanisms. HF-induced hemodynamic disturbances reshape the gut microenvironment, leading to the collapse of intestinal physical and immune barrier functions. In this altered microenvironment, dysregulated gut bacteria release excessive pro-inflammatory metabolites while reducing protective signaling molecules, thereby activating inflammatory pathways including Toll-Like Receptor 4/Nuclear Factor-κB and NOD-like receptor protein 3 inflammasomes. Traditional Chinese medicine (TCM) is the most import integrative medicine to treat HF, and the combination of TCM and western medicine have reached certain progress. This article aims to describe the pathological feedback mechanism between HF and gut microbiota, as long as summary how TCM and western medicine treat HF through regulate gut-heart axis. In specific, modern medicine optimizes hemodynamics to improve the macroscopic microenvironment, thereby establishing a foundation for gut microbiota remodeling. TCM exerts holistic regulatory advantages through multiple components and targets, inhibiting the production of gut-derived inflammatory factors at their source by reshaping the oxygen gradient, providing prebiotic substrates, and repairing intestinal barrier integrity. These could provide a theoretical basis and research reference for precision-oriented HF prevention and management from the perspective of intestinal microecology.