Abstract: Objective To investigate the clinical efficacy of Xinglou Chengqi Decoction combined with conventional Western medicine therapy in patients with acute ischemic stroke (AIS) complicated with stroke-associated pneumonia (SAP) of phlegm-heat fuexcess syndrome, and its effects on inflammatory factors and brain-gut peptides. Methods A total of 150 patients with AIS complicated with SAP of phlegm-heat fu-excess syndrome admitted and treated at Changzhou Traditional Chinese Medicine Hospital from January 2024 to May 2025 were divided into a control group (conventional Western medicine therapy) and an observation group (conventional Western medicine therapy plus Xinglou Chengqi Decoction) by random number table, with 75 cases in each group, and all patients were treated continuously for 10 days. The two groups were compared in terms of clinical efficacy on day 10 of treatment, time to clinical symptom resolution, levels of inflammatory factors, brain-gut peptides and clinical scores before treatment and on days 3 and 10 after treatment; as well as incidence of adverse reactions during treatment. Results Compared with the control group, the observation group demonstrated a significantly higher total effective rate and shorter time to clinical symptom resolution (P < 0.05). On days 3 and 10 after treatment, the observation group showed significant reductions in the levels of inflammatory factors and clinical scores, along with notable increases in brain-gut peptides levels (P < 0.05). There was no statistically significant difference in the incidence of adverse reaction between the two groups (P > 0.05). Conclusion Xinglou Chengqi Decoction combined with conventional Western medicine therapy can improve the clinical efficacy in patients with AIS complicated with SAP of phlegm-heat fu-excess syndrome, regulate the levels of inflammatory factors and brain-gut peptides, and shorten time to clinical symptom resolution. This combined regimen has few adverse reactions and is safe and reliable for clinical application.