Objective To investigate the clinical efficacy and safety of enhanced external counterpulsation (EECP) in improving subclinical atherosclerosis (SCA) in patients with primary hypertension. Methods A retrospective analysis was conducted on the clinical data of 86 patients with essential hypertension (EH). All patients received EECP therapy with a planned course of 35 sessions (actual completion: 30～35 sessions). Vascular functional parameters, including carotid intima-media thickness (CIMT), ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV), ambulatory arterial stiffness index (AASI), and flow-mediated dilation (FMD), were compared before and after treatment. Changes in these indicators were analyzed according to cardiovascular risk stratification based on the 2024 Chinese Guidelines for the Prevention and Treatment of Hypertension. Additionally, independent factors influencing CIMT improvement were identified using multiple linear regression. Results After treatment, CIMT, baPWV, and AASI significantly decreased, while FMD and ABI significantly increased (all P＜0.05). Subgroup analysis revealed that patients with higher cardiovascular risk stratification showed more pronounced reductions in CIMT. Multiple linear regression analysis showed that the actual number of EECP sessions (β＝-0.486), baseline systolic blood pressure (SBP) (β＝0.352), and duration of hypertension (β＝0.318) were independent predictors of CIMT improvement (all P＜0.05). No serious adverse events occurred during the treatment period. Conclusion EECP can effectively improve arterial stiffness and endothelial function in hypertensive patients, delay the progression of SCA, and demonstrates a favorable safety profile. It may serve as a promising physical intervention strategy for the prevention and treatment of early vascular lesions in hypertension.