TCM and probiotics may offer a promising direction for future precision prevention and management of coronary heart disease

Gut microbiota has emerged as an important contributor to the pathogenesis and progression of coronary heart disease (CHD). Increasing evidence indicates that gut dysbiosis promotes atherosclerosis and cardiovascular dysfunction through microbiota-derived metabolites, including trimethylamine N-oxide (TMAO), short-chain fatty acids (SCFAs), and bile acid-related pathways, as well as through effects on inflammation, cholesterol metabolism, endothelial injury, and intestinal barrier integrity. In recent years, phytomedicine, particularly Traditional Chinese Medicine (TCM), has attracted growing attention as a microbiota-modulating strategy because of its multi-component, multi-target, and system-level regulatory properties. In parallel, probiotics may provide targeted supplementation of beneficial strains and functional pathways. This review summarizes the major microbiota-mediated mechanisms involved in CHD and examines how phytomedicine regulates gut microbial composition, microbial metabolism, host inflammatory responses, and barrier function. We further discuss the complementary potential of phytomedicine and probiotics, highlighting their possible synergistic roles in restoring microbial ecology and improving cardiometabolic homeostasis. In addition, we critically evaluate current limitations in the field, including insufficient standardization of phytomedicine–probiotic combinations, heterogeneity of host–microbiota responses, limited clinical evidence, and unresolved long-term safety issues. Overall, this review provides an ethnopharmacology-oriented and mechanistically integrated perspective on microbiota-targeted interventions in CHD, and suggests that phytomedicine-based modulation, alone or in combination with probiotics, may represent a promising direction for future precision prevention and management of CHD.