Efficacy and safety of selected Chinese herbal medicine preparations in treating carotid atherosclerosis: a systematic review and meta-analyses

Background Although conventional therapies for Carotid atherosclerosis (CAS) remain the standard treatment, their effectiveness is often limited and accompanied by adverse effects. Chinese herbal medicine (CHM) is a promising adjunctive therapy for CAS; however, robust clinical evidence supporting its efficacy and safety remains limited. Objective This systematic review and meta-analysis evaluates the efficacy and safety of CHM for CAS treatment and characterizes its medication patterns. Methods Five databases were searched from inception to December 2025. Randomized controlled trials (RCTs) evaluating oral CHM for CAS were included. Study quality was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. Data were extracted and analyzed using RevMan v5.3 and R software. Sources of heterogeneity were investigated through meta-regression and subgroup analyses. Network analysis reveals herbal medication patterns across 21 studies. Results Twenty-one RCTs involving 3,078 patients were included. Compared with conventional therapy alone, adjunctive CHM significantly reduced carotid plaque area (MD = 4.94, 95% CI: 3.13 to 6.76, p < 0.01), intima-media thickness (IMT) (MD = 0.12, 95% CI: 0.07 to 0.17, p < 0.05), total cholesterol (TC) (MD = 0.32, 95% CI: 0.22 to 0.42, p < 0.01), triglycerides (TG) (MD = 0.24, 95% CI: 0.11 to 0.37, p < 0.01), and low-density lipoprotein cholesterol (LDL-C) (MD = 0.37, 95% CI: 0.21 to 0.53, p < 0.01), while greatly increasing high-density lipoprotein cholesterol (HDL-C) (MD = −0.20, 95% CI: −0.29 to −0.10, p < 0.01). CHM did not significantly increase the risk of adverse events (RR = 0.84, 95% CI: 0.64 to 1.10, p = 0.20) or impair liver/kidney function. Network analysis identified core actions as clearing phlegm and removing blood stasis, with Danshen (Salvia miltiorrhiza Bge.) and Banxia [Pinellia ternata (Thunb.) Breit.] as pivotal botanical drugs exerting anti-stasis and lipid-regulating effects. Conclusion As an adjunct to conventional therapy, CHM may further reduce carotid IMT and plaque burden, improve lipid metabolism, and demonstrate a favorable safety profile. However, the overall quality and heterogeneity of the included studies limit the strength of the evidence, highlighting the need for well-designed, high-quality RCTs to confirm these findings. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261285381 , identifier CRD420261285381.