Evidence mapping of Zhenwu decoction for chronic heart failure

Objective: Chronic heart failure (CHF) remains associated with symptom burden, recurrent hospitalization, and reduced quality of life despite guideline-directed therapy. Zhenwu Decoction (ZWD), a classical traditional Chinese medicine formula, is used as adjunctive therapy for yang-deficiency and fluid-retention patterns. This evidence map aimed to characterize the volume, distribution, methodological quality, and evidence gaps in clinical research on ZWD for CHF. Methods: We searched CNKI, VIP, Wanfang, CMJ, SinoMed, PubMed, Web of Science, Embase, the Cochrane Library, ClinicalTrials.gov, ITMCTR, and ChiCTR from inception to 2 March 2025. Randomized controlled trials (RCTs), systematic reviews, and meta-analyses evaluating original or modified ZWD for CHF were eligible. Broad heart-failure terms were used for search sensitivity, but final eligibility was restricted to CHF. RCTs were assessed with the Cochrane risk-of-bias tool, and systematic reviews/meta-analyses were assessed with AMSTAR-2 and PRISMA 2020. Results: After exclusion of one acute heart failure study, the revised evidence base comprised 166 RCTs and 14 systematic reviews/meta-analyses. All included clinical studies were conducted in China and were generally single-center, small-sample, and short-duration trials with limited follow-up. Commonly reported outcomes included left ventricular ejection fraction, New York Heart Association functional class, and natriuretic peptide levels. The most frequently reported traditional Chinese medicine syndrome patterns were heart-kidney yang deficiency and yang deficiency with water retention. Important limitations included incomplete reporting of randomization, allocation concealment, blinding, protocol registration, follow-up, and adverse events. All included systematic reviews/meta-analyses were rated as critically low quality by AMSTAR-2. Conclusion: Current evidence suggests potential adjunctive signals for ZWD in CHF, but the certainty of evidence remains low. Future studies should use prospectively registered, adequately powered, multicenter RCTs with standardized syndrome differentiation, longer follow-up, clinically meaningful endpoints, and rigorous safety monitoring.