Taoren Honghua Jian Regulate NLRP3 Inflammasome of Coronary Artery Disease Patients: A Multi-Center, Double-Blind, Randomized Controlled Trial

Introduction

Coronary artery disease (CAD) continues to rank as the third leading global cause of death, accounting for an estimated 17.8 million annual fatalities.¹ At the heart of its progressive vascular pathology lies the NLRP3 inflammasome, a multiprotein cytosolic sensor that drives maladaptive innate immunity. Triggered by cholesterol crystals and reactive oxygen species, NLRP3 assembles with the adaptor ASC and pro-caspase-1, enabling proteolytic maturation of IL-1β and IL-18.² The resulting cytokine surge intensifies endothelial injury, recruits proinflammatory macrophages, and weakens the fibrous cap, thereby promoting plaque instability and precipitating acute coronary syndromes.³ Clinical studies further reveal elevated NLRP3 expression in peripheral blood mononuclear cells (PBMCs) of CAD patients, correlating with disease severity and poor prognosis.⁴ These insights have positioned NLRP3 inflammasome signaling as a promising therapeutic node, exemplified by the CANTOS trial in which selective IL-1β blockade achieved a 15% reduction in recurrent myocardial infarction.⁵ Nevertheless, broad IL-1β inhibition increases susceptibility to serious infections, highlighting the pressing requirement for more precise, multi-pathway anti-inflammatory approaches with improved safety profiles.⁶

Traditional Chinese Medicine (TCM) has emerged as a valuable integrative option, rooted in the classical theory of “Qi stagnation and blood stasis” that views CAD as a systemic imbalance rather than an isolated vascular lesion.⁷ Patients exhibiting this pattern—typically angina pectoris accompanied by a purplish tongue and a string-like pulse—display clear evidence of microvascular impairment and sustained subclinical inflammation that overlaps mechanistically with NLRP3 inflammasome hyperactivity.⁸ A representative intervention is Taoren Honghua Jian (THJ), an ancient prescription preserved in Su’an Consilia that combines eleven carefully selected herbs to restore Qi dynamics, dispel stasis, and simultaneously dampen multiple inflammatory cascades. In routine clinical practice within the framework of TCM syndrome differentiation, THJ is primarily prescribed for patients with CAD presenting with the hallmark patterns of Qi stagnation and blood stasis, characterized by fixed, stabbing chest pain, a dark purplish tongue, and a wiry or choppy pulse. The conventional dosage in decoction form is one package daily, typically administered in two divided doses, with a common treatment course ranging from 4 to 12 weeks depending on symptom severity and chronicity. This clinical rationale and dosing framework directly informed the design of our trial, including the patient selection criteria (Qi stagnation and blood stasis syndrome) and the 4-week intervention period. Clinical studies have shown that THJ can significantly improve the TCM syndrome, angina pectoris symptoms and the frequency of nitroglycerin usage of patients with Qi stagnation and blood stasis syndrome.^9,10 However, these previous studies primarily focused on clinical symptoms and lacked investigation into the underlying molecular mechanisms, particularly concerning inflammation. Although preclinical studies indicate that THJ harbours considerable potential to attenuate NLRP3 inflammasome activation, its clinical translation into routine CAD therapy is hampered by the scarcity of high-quality human trials directly assessing this effect. Key components like salvianolic acid (from Salviae miltiorrhizae) emerges as a potent bioactive modulator that attenuates NLRP3 activation, thereby effectively suppressing neuroinflammatory cascades and downstream apoptotic pathways in neuronal tissues.¹¹ In our previous studies, amygdalin (from Prunus persica (L). Batsch) and hydroxysafflor yellow A (from Carthamus tinctorius L), which could inhibit inflammatory response.^12,13

This prospective multicenter, double-blind, randomized, placebo-controlled trial was specifically designed to resolve two fundamental uncertainties in the integrative management of stable coronary artery disease. First, whether THJ can meaningfully relieve anginal symptoms and enhance health-related quality of life among patients presenting with the classical TCM pattern of Qi stagnation and blood stasis. Second, whether THJ exerts measurable anti-inflammatory effects by suppressing NLRP3 inflammasome activation within peripheral blood mononuclear cells. We enrolled 120 patients across three Shanghai hospitals, administering THJ granules (18.3 g twice daily) or placebo for four weeks alongside standard care. Clinical outcomes—assessed via TCM syndrome score (TCMSS) and Seattle Angina Questionnaire (SAQ)—were complemented by molecular analyses of NLRP3, ASC, caspase-1, IL-1β, and IL-18 in PBMCs and plasma. By bridging TCM syndrome differentiation with inflammasome biology, this study pioneers a translational framework to validate traditional formulas through modern biomarkers. If successful, it will establish THJ as a dual-action therapy: alleviating symptoms through Qi regulation while targeting NLRP3-driven inflammation at its root—a paradigm shift toward precision-integrated CAD management. As far as we know, no similar studies were explored by other teams before.

Methods

Trial Design

The study protocol was approved by the Ethics Committee of Longhua Hospital, Shanghai University of Traditional Chinese Medicine (Approval No. 2019LCSY008) and conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines (Supplementary File 1). This trial was prospectively registered in the Chinese Clinical Trial Registry (Registration No. ChiCTR1900021772). Written informed consent was obtained from all participants prior to enrollment. The protocol was shown in Figure 1 and published (https://pubmed.ncbi.nlm.nih.gov/31689832/).

Figure 1 Schedule of enrollment and assessments. Abbreviations: THJ, Taoren Honghua Jian granule; ITSS, Integral TCM syndrome score; SAQ, Seattle Angina Questionnaire; IF, inflammation indexes; NLRP3, NOD-like receptor thermal protein domain associated protein 3; √, need to check; , take THJ or THJ placebo.

Participants

The trial recruited its eligible patient cohort through a multicenter collaboration involving three tertiary institutions in Shanghai, China: Longhua Hospital affiliated with Shanghai University of Traditional Chinese Medicine, Gongli Hospital of Shanghai Pudong New Area, and Shanggang Community Health Service Center of Shanghai Pudong New Area. Enrollment was conducted continuously between June 2019 and December 2023.

Inclusion Criteria

CAD Diagnosis

All enrolled participants were required to meet the 2013 European Society of Cardiology criteria for coronary artery disease,¹⁴ confirmed through objective documentation of significant coronary atherosclerosis or prior ischemic events. This included angiographic or CT angiographic evidence of ≥50% luminal stenosis in at least one major epicardial artery, a history of myocardial infarction, previous revascularization by percutaneous coronary intervention or coronary artery bypass grafting, or positive findings on myocardial perfusion imaging. In addition, patients had to demonstrate clinically stable angina—defined as unchanged frequency, duration, and precipitating factors for at least 60 days—with chest pain that reliably responded to sublingual nitroglycerin and no evidence of recent myocardial necrosis.

Age

18–70 years.

TCM Syndrome Differentiation

According to the 2002 Guidelines for Clinical Research on New Chinese Medicines, a confirmed diagnosis of this syndrome requires a hierarchical diagnostic approach: the presence of cardinal symptoms, specifically chest tightness or chest pain, is mandatory, accompanied by at least two secondary manifestations such as fixed stabbing pain or symptom exacerbation triggered by emotional stress. These clinical features must further be corroborated by characteristic objective signs, including a purple or dark tongue and a wiry or choppy pulse. The application of this multi-dimensional diagnostic framework ensures the homogeneity of enrolled participants with respect to TCM syndrome classification, thereby enhancing the accuracy and comparability of therapeutic efficacy assessments in TCM intervention trials.

Informed Consent

Participants’ full informed consent and voluntary adherence to study protocols constitute a fundamental prerequisite for maintaining ethical compliance and ensuring data integrity throughout the clinical trial process.

Exclusion Criteria

Participants were excluded if they presented with acute coronary syndrome, heart failure, or cardiovascular neurasthenia. Those with severe hypertension (systolic BP ≥ 180 mmHg), cardiopulmonary dysfunction, or arrhythmias were also ineligible. Additional exclusion criteria encompassed psychiatric disorders including severe mania, depression, or suicidal ideation, as well as active infectious diseases such as tuberculosis, hepatitis B, or HIV. Patients with significant hepatic or renal impairment, defined as ALT or AST exceeding three times the upper limit of normal or eGFR below 30 mL/min/1.73 m², were similarly excluded. Furthermore, individuals with known hypersensitivity to the study medications or those unable to complete the required follow-up were not eligible for enrollment.

Sample Size Calculation

A pre-experiment comparing THJ and placebo in CAD patients was conducted between June and December 2018. Sample size was estimated using the formula , N1 and N2 are the patient numbers in THJ group and placebo group; Z_(1-α)= 1.96 when α = 0.05; Z_(1-β)= 1.282 when 1-β = 0.90; σ (standard deviation of two groups) = 7.7; k=1; μ_r-μ_c (the difference of TCMSS in THJ and placebo group) = 3.4; ∆ = 0. Based on these parameters, a total of 120 participants (60 per group) were deemed sufficient to detect clinically meaningful differences in TCMSS between groups at a two-sided significance level of 5% with 90% statistical power.

Randomization, Blinding and Allocation

Participants were randomized using a stratified approach, with age and gender as stratification factors, at a 1:1 allocation ratio (block size = 4) generated via SPSS 26.0 (IBM Corp., USA). Randomization codes were produced by an independent statistician who was not involved in participant care or outcome assessment. Group assignments were concealed in sequentially numbered, opaque sealed envelopes and distributed to eligible participants upon enrollment. Investigators, participants, outcome assessors, and statisticians remained blinded throughout data collection, analysis, and interpretation to minimize performance and detection bias.

Intervention

All participants received guideline-directed standard care, including sublingual nitroglycerin as needed for acute angina relief. Quality control reports for the herbal and placebo preparations are provided in Supplementary Files 2 and 3.

Intervention Group

Patients were administered THJ granules (Peili Medical and Pharmaceutical Co., Ltd., China; Batch No. 2019THD-01), prepared as a water-soluble extract comprising 11 herbal constituents: Prunus persica L. Batsch (Taoren, 10 g), Carthamus tinctorius L. (Honghua, 10 g), Salvia miltiorrhiza Bunge (Danshen, 15 g), Corydalis yanhusuo (Yanhusuo, 10 g), Ligusticum striatum (Chuanxiong, 10 g), Bupleurum sibiricum (Chishao, 15 g), Angelica sinensis (Danggui, 12 g), Rehmannia glutinosa (Shengdi, 10 g), Pericarpium Citri Reticulatae Viride (Qingpi, 10 g), Cyperus rotundus (Xiangfu, 10 g), and Boswellia carteri (Ruxiang, 3 g). Each dose (18.3 g) was dissolved in 150 mL of hot water and taken orally twice daily over a 4-week treatment period.

Control Group

Placebo granules (Batch No. 2019PLC-01) were formulated to match THJ in appearance, odor, and taste, consisting of 90% inert excipients (lactose, starch, and food-grade pigments) with 10% crude THJ extract incorporated solely for flavor mimicry.

Monocyte and RNA Isolation

At baseline and following the intervention, 10 mL blood was drawn from each participant via antecubital venipuncture using EDTA-coated collection tubes. Following centrifugation at 1,500 × g for 10 minutes at room temperature, the supernatant plasma was carefully aliquoted and cryopreserved at −80°C for subsequent cytokine profiling. PBMCs were then separated from the remaining blood sample by density gradient centrifugation using Ficoll-Hypaque reagent (Tianjin Haoyang Biological Products Technology, China). Prior to layering, blood was diluted in an equal volume of PBS and gently overlaid onto 15 mL of Ficoll solution, followed by centrifugation at 2,000 × g for 15 minutes. The buffy coat containing PBMCs was carefully harvested, subjected to two PBS washes, and concentrated by centrifugation at 400 × g for 5 minutes. RNA extraction was performed on the resultant cell pellet with the RNA Purification Kit (Thermo Fisher Scientific, USA), after which complementary DNA synthesis was carried out using the PrimeScript RT Reagent Kit (Takara Bio, Japan) per the manufacturer’s recommended protocol. The integrity of all RNA samples was assessed by agarose gel electrophoresis prior to downstream analysis, with an RNA integrity number of >7.0 set as the acceptance threshold.

Main Outcome: TCMSS

TCMSS was evaluated at each follow-up visit in accordance with the Guiding Principles of Clinical Research on New Traditional Chinese Medicine (2002 edition). The assessment instrument encompasses both symptomatic and physical sign domains, covering eight items: angina, chest pain, palpitations, vexation, insomnia, lassitude, dizziness, and lip/fingernail discoloration. Each item is graded across four severity levels, yielding a composite score ranging from 0 to 33, where higher scores indicate greater disease burden. Detailed scoring criteria are provided in Supplementary Tables 1 and 2.

Secondary Outcomes

SAQ

The SAQ was employed to evaluate angina-related health status across five subscales: physical limitation (PL), angina stability (AS), angina frequency (AF), treatment satisfaction (TS), and disease perception (DP). Raw scores within each domain were standardized using the following transformation: , with higher scores reflecting more favorable clinical status. This assessment was administered at both baseline and 4 weeks post-treatment. Comprehensive scoring criteria are detailed in Supplementary Table 3.

Lipid Levels

Fasting venous blood samples were collected at baseline and at 4 weeks post-treatment to evaluate lipid metabolism parameters. Four indices were measured: triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C).

Inflammation Indexes

Plasma levels of hs-CRP (PC190), TNF-α (PT518), IL-1β (PI305), IL-2 (PI580), IL-6 (PI325), IL-8 (PI640), IL-10 (PI528), and IL-18 (PI558) were measured via ELISA methods using standardized kits (Beyotime, China).

NLRP3 Inflammasome Components

The mRNA expression of key NLRP3 inflammasome constituents, including NLRP3, ASC, caspase-1, IL-1β, and IL-18, was quantified by SYBR Green-based quantitative PCR using a QuantStudio 5 Real-Time PCR System (Applied Biosystems, USA). Target-specific primer sequences (Supplementary Table 4) were designed via Primer-BLAST (NCBI) and commercially synthesized by Sangon Biotech (China). Each 20 μL reaction was prepared with 10 μL TB Green Premix Ex Taq II (Takara Bio), 1 μL cDNA template, and 0.2 μM of each primer. Thermal cycling parameters consisted of an initial denaturation at 95°C for 30 seconds, followed by 40 cycles of 95°C for 5 seconds and 60°C for 30 seconds. Primer specificity was verified through melt curve analysis. β-actin was used as the reference gene, and relative expression levels were determined by the 2^−ΔΔCT method with all samples analyzed in technical triplicates.

Safety Assessments

Safety monitoring was performed throughout the trial and encompassed hematological and biochemical evaluations, including complete blood count, hepatic function indices (ALT and AST), and renal function markers (BUN and creatinine). Serial electrocardiograms were obtained to detect any treatment-emergent arrhythmias or ischemic changes. All adverse events, such as gastrointestinal discomfort or allergic reactions, were systematically recorded with documentation of onset time, duration, severity grading, and causality assessment in relation to the study intervention.

Statistical Analysis

All statistical analyses were carried out using SPSS 26.0 (IBM Corp., USA). Data normality was evaluated by the Shapiro–Wilk test. Normally distributed continuous variables are presented as mean ± SD, non-normally distributed variables as median (interquartile range), and categorical variables as frequencies with percentages. All 120 participants were analyzed following the intention-to-treat principle. For between-group comparisons, independent t-tests or Mann–Whitney U-tests were employed for continuous variables depending on data distribution, while chi-square test or Fisher’s exact test was applied to categorical data. Kaplan-Meier survival curves with Log rank tests were used for time-to-event endpoints. For analyses involving multiple related endpoints (inflammatory cytokines and NLRP3 inflammasome components), P-values were adjusted using the Benjamini–Hochberg false discovery rate (FDR) correction, with an FDR threshold (q-value) of 0.05. All tests were two-sided, and a P-value < 0.05 was considered statistically significant. Missing data (< 5% of cases) were handled via multiple imputation using the fully conditional specification method.

Results

Baseline Characteristics

Enrollment took place between June 2019 and December 2023, during which 120 eligible participants were allocated to either the THJ group (n = 60) or the placebo group (n = 60). In the placebo group, 3 patients were lost to follow‑up because they could not return to the hospital after 4 weeks due to the COVID‑19 epidemic. In the THJ group, 2 patients were lost to follow‑up for the same reason. In addition, 3 patients discontinued intervention in THJ group and 5 in placebo group for different reasons (Details in Figure 2). Demographic and clinical characteristics at baseline are summarized in Table 1. No statistically significant between-group differences were identified in any baseline parameter (P > 0.05), indicating successful randomization and adequate group comparability.

Table 1 Baseline Characteristics of Participants

Figure 2 Enrollment of study participants. Flow chart of participant process, including randomization, intervention/control treatment, finishing follow-up, and inclusion in primary endpoint analysis.

Comparison of TCMSS

TCMSS baseline was comparable between the two groups prior to treatment, with no statistically significant intergroup difference detected (P > 0.05). THJ group consistently achieved greater score reductions than the placebo group across all assessed timepoints (P < 0.01) (Figure 3).

Figure 3 Comparison of TCMSS between THJ and placebo groups before and after treatment. Data were represented as mean ± SD. Compared to the placebo group at the timepoint, **P< 0.01.

SAQ Scores

THJ treatment was associated with significant improvements across all five SAQ domains compared to placebo. As illustrated by radar chart analysis (Figure 4), patients in the THJ group demonstrated clinically meaningful gains in PL, AS, AF, TS, and DP following the intervention. Within-group comparisons revealed that SAQ dimension scores were significantly elevated from baseline at week 4 in the THJ group (P < 0.01), and this superiority over the placebo group was sustained through week 8 (P < 0.01), as presented in Table 2. These findings collectively indicate that THJ granules confer a comprehensive and durable benefit on angina-related health status.

Table 2 Comparison of Seattle Angina Questionnaire Scores Between Groups (ITT-Analysis)

Figure 4 Comparisons of SAQ scores. (A) Before THJ intervention, SAQ scores of THJ and placebo group. (B) After 4 weeks intervention, the red line is SAQ score of THJ group and blue line represents the placebo group. (C) SAQ score of placebo group at the baseline (red line), 2 weeks (blue line), and 4 weeks (green line). (D) SAQ score of THJ group at the baseline (red line), 2 weeks (blue line) and 4 weeks (green line). Data were represented as mean ± SD. Compared to the placebo group at the timepoint.

Lipid Levels

Baseline lipid levels were well-matched between the THJ and placebo groups, with no statistically significant differences detected in TG, TC, HDL-C, or LDL-C, confirming adequate comparability between groups prior to intervention. Following 4 weeks of treatment, between-group comparisons revealed no significant differences in any of the assessed lipid parameters. These findings indicate that THJ granules conferred no additional effect on lipid metabolism relative to placebo over the study period (Table 3).

Table 3 Comparison of Lipid Levels Between the Two Groups of Patients (ITT-Analysis)

Comparison of Inflammatory Cytokines and NLRP3 Inflammasome in PMBCs

Following 4 weeks of treatment, circulating levels of IL-1β, IL-2, and IL-18 were significantly reduced in the THJ group relative to placebo (P < 0.01), whereas IL-6, IL-8, IL-10, TNF-α, and hs-CRP did not differ significantly between groups (Table 4). At the transcriptional level, NLRP3 inflammasome component mRNA expression—encompassing NLRP3, ASC, caspase-1, IL-1β, and IL-18—was quantified in PBMCs at baseline and week 4. THJ intervention resulted in significant downregulation of all measured inflammasome transcripts compared to placebo (P < 0.01), as shown in Figure 5. Missing data of participants were handled via multiple imputation using the fully conditional specification method. Additionally, stability of β-actin was verified across treatment conditions (Supplementary Figure 1).

Table 4 Comparison of Inflammatory Cytokines Between Groups (ITT-Analysis)

Figure 5 Relative expression of NLRP3, ASC, caspase-1, IL-1β and IL18 mRNA in PBMCs from CAD patients treated with THJ or placebo for four weeks. Data were represented as mean ± SD. Compared to the placebo group, **P<0.01. Three replicates were performed.

Safety Assessments and Adverse Reactions

THJ granules were well-tolerated throughout the trial. No serious adverse events were recorded in either group, including gastrointestinal hemorrhage, hepatotoxicity, nephrotoxicity, thrombocytopenia, or coagulopathy. Laboratory safety indices remained within normal clinical reference ranges in both groups, with no statistically significant pre- to post-intervention changes or between-group differences observed (P > 0.05) (Table 5).

Table 5 Comparison of Adverse Reactions Between Groups

Discussion

Study Summary

This multicenter RCT demonstrates that THJ, administered adjunctively to guideline-directed standard care, significantly ameliorates angina symptoms and attenuates NLRP3 inflammasome activation in patients with stable CAD presenting with Qi stagnation and blood stasis syndrome. At the clinical level, THJ produced superior reductions in TCMSS relative to placebo and yielded meaningful improvements across all SAQ domains, most notably in physical limitation and angina frequency, reflecting enhanced functional status. At the molecular level, THJ significantly downregulated PBMC mRNA expression of NLRP3, ASC, caspase-1, IL-1β, and IL-18, accompanied by concurrent reductions in circulating IL-1β, IL-2, and IL-18. To our knowledge, this represents the first clinical evidence validating a TCM formula as a targeted modulator of the canonical NLRP3-ASC-caspase-1 inflammasome axis in humans.

Clinical Significance and Comparative Advantages

THJ showed a greater reduction in TCMSS and SAQ dimensions observed in the THJ group at week 4 are consistent with its pronounced anti-inflammatory activity, as evidenced by concurrent downregulation of NLRP3/IL-1β axis transcripts and circulating inflammatory cytokines relative to placebo. THJ exerts its therapeutic effects primarily through promoting blood circulation, resolving blood stasis, regulating Qi, and dredging collaterals, making it a well-established formula for the clinical management of Qi stagnation and blood stasis syndrome. The integration of THJ with conventional Western pharmacotherapy represents a widely adopted strategy in CAD management. Contemporary pharmacological investigations have demonstrated that bioactive constituents of key THJ herbs—including Carthamus tinctorius L., Ligusticum striatum, and Salvia miltiorrhiza Bunge—possess anti-inflammatory, antioxidant, and neuroprotective properties, with established clinical applications in hypertension, coronary atherosclerotic heart disease, stroke, and related cardiovascular and cerebrovascular conditions.^15,16 We also tested the main components of THJ showed in Table 6. The present study further substantiates the therapeutic value of THJ by demonstrating its capacity to suppress NLRP3 inflammasome activation and reduce downstream IL-1β and IL-18 secretion in CAD patients, supporting its potential as a short-term adjunctive therapy with measurable immunomodulatory benefits.

Table 6 Main Components of THJ

Integration with Current Evidence

Our PBMC-level findings corroborate the association between NLRP3 expression and CAD severity previous report.¹⁷ Notably, THJ’s simultaneous suppression of both upstream (NLRP3) and downstream (IL-18) inflammasome components represents a mechanistic advantage over conventional statins, which exert only modest inflammasome-modulatory effects and may inadequately address residual inflammatory risk.¹⁸ The NLRP3 inflammasome is an emerging intracellular sensor of pivotal importance in cardiovascular pathophysiology.¹⁹ As a cytosolic pattern-recognition receptor of the NOD-like receptor family, NLRP3 detects both pathogen-associated molecular patterns and danger-associated molecular patterns, triggering assembly of a multiprotein inflammasome complex. This leads to caspase-1 activation and proteolytic processing of pro-IL-1β and pro-IL-18 into their biologically active forms, thereby initiating a self-amplifying inflammatory cascade.²⁰ Substantial evidence implicates this pathway in the pathogenesis of atherosclerotic vascular disease, with IL-1β and IL-18 recognized as potent proatherogenic mediators.²¹ IL-1β orchestrates downstream inflammatory signaling central to atherogenesis, while IL-18 has been independently associated with coronary event risk and plaque instability in human carotid lesions.²² The clinical relevance of targeting this inflammatory axis is further underscored by the landmark CANTOS trial, which demonstrated that selective IL-1β inhibition with canakinumab significantly reduced recurrent cardiovascular events in post-myocardial infarction patients.^18,23 THJ’s capacity to modulate multiple nodes of the NLRP3-IL-1β/IL-18 axis through a multi-constituent botanical approach may therefore represent a complementary and potentially more accessible therapeutic strategy for addressing inflammasome-driven cardiovascular risk.

Limitations

Despite the encouraging short-term findings, the present study has several limitations that temper interpretation and warrant future investigation. Recruitment was confined to a single metropolitan region (Shanghai), which may restrict the generalizability of results to more diverse geographic and ethnic populations. In addition, while the study demonstrated suppression of key inflammatory markers, the mechanistic depth was constrained by the absence of direct assays measuring essential components of NLRP3 inflammasome activation—specifically, ASC speck formation and caspase-1 activity in PBMCs. This gap limits our ability to conclusively attribute the observed anti-inflammatory effects to direct NLRP3 pathway inhibition. Finally, the relatively brief 8-week follow-up period precludes evaluation of sustained cardiovascular protection or delayed safety signals, both of which are essential considerations for any therapy targeting a chronic condition such as stable coronary artery disease.

Future Research Implications

To comprehensively validate and advance the therapeutic potential of THJ, several targeted research avenues warrant prioritization. First, large-scale, multicenter Phase III clinical trials should be initiated to rigorously evaluate the impact of THJ on definitive clinical endpoints, particularly major adverse cardiovascular events. Such trials are essential to establish robust clinical efficacy and safety profiles. Concurrently, detailed pharmacokinetic studies must characterize the absorption, distribution, metabolism, and excretion profiles of THJ’s key bioactive constituents—notably hydroxysafflor yellow A—to elucidate their bioavailability, active metabolites, and exposure-response relationships. This pharmacokinetic foundation is critical for optimizing dosing regimens and understanding intersubject variability. Furthermore, leveraging cutting-edge single-cell RNA sequencing technology could precisely delineate the specific monocyte subpopulations in which THJ exerts its NLRP3 inflammasome-suppressing effects, thereby uncovering novel cellular and molecular mechanisms underlying its anti-inflammatory activity and identifying potential biomarkers of response. In addition, while the present trial was not designed with a specific minimal clinically important difference (MCID) for SAQ threshold as the primary endpoint, the observed improvements in all the domains reached statistical significance. We acknowledge that the clinical interpretation of patient-reported outcomes requires consideration of both statistical and clinical significance. To further quantify the therapeutic benefit, future larger-scale studies should establish the MCID for SAQ in this patient population treated with THJ and report the responder rate, thereby allowing for a more refined assessment of its clinical value.

Conclusion

This trial provides evidence that THJ alleviates Qi stagnation and blood stasis syndrome by suppressing the NLRP3-IL-1β/IL-18 axis and inflammation in CAD patients. Its excellent safety profile and compatibility with standard therapies support THJ’s integration into precision-guided CAD management. By bridging TCM syndrome differentiation with inflammasome biology, we establish a paradigm for evaluating traditional formulas through mechanistic biomarkers—advancing the global convergence of traditional and contemporary medicine.