Abstract: Cardiac diseases have complex pathogenesis and diverse syndromes, with traditional syndrome differentiation and prescription facing bottlenecks like difficult formula selection, fluctuating curative effects, and insufficient integration of “principles, methods, medicines and prescriptions”. Based on TCM classic theories and clinical practice, this paper proposes the “similar prescriptions as guidance” strategy. It first sorts out three core pathogenesis categories of cardiac diseases: obstruction of cardiac vessels, malnutrition of the heart, and disturbance of the mind, key pathological factors (phlegm, fire, stagnation, blood stasis, deficiency, mental disorder) and core therapeutic methods including promoting blood circulation and removing blood stasis, resolving phlegm and calming the mind, clearing heat and relieving irritability, soothing the liver and relieving depression, warming yang and tonifying qi, and nourishing yin and tranquilizing the mind. Then, guided by core pathogenesis, therapies and medicinal ingredients, it integrates traditional prescriptions into eight similar prescription systems: Banxia similar prescriptions, Zhizi similar prescriptions, Chaifu similar prescriptions, Danhong similar prescriptions, Shenqi similar prescriptions, Guifu similar prescriptions, Shengdi similar prescriptions, and Longmu similar prescriptions. A four-step clinical decision pathway (“determine disease location-identify pathogenesis-select similar prescriptions-modify flexibly”) is built to realize systematic connection from pathogenesis identification to medication. This strategy provides a concise and efficient TCM diagnosis and treatment mode for cardiac diseases, improving prescription accuracy and curative effect repeatability, with theoretical innovation and clinical promotion value.