ObjectiveTo explore the predictive value of blood pressure variability (BPV) on carotid atherosclerosis (CAS) in elderly patients with heart failure with preserved ejection fraction (HFpEF).MethodsA retrospective study was conducted on 198elderly patients with HFpEF admitted to the Kaifeng People’s Hospital from January 2023 to June 2025. Patients were divided into the occurrence group (n＝37) and the non-occurrence group (n＝161) based on whether they had CAS. The clinical data of the two groups were compared, and the predictive value of BPV on CAS in elderly HFpEF patients was emphatically analyzed.ResultsThe proportion of hypertension, as well as the levels of high-sensitivity troponin T (hs-cTnT) and homocysteine (Hcy) were higher in the occurrence group than those in the non-occurrence group (all P＜0.05). The 24-hour systolic blood pressure standard deviation (24 h SSD), daytime systolic blood pressure standard deviation (dSSD), and nighttime systolic blood pressure standard deviation (nSSD) were all higher in the occurrence group relative to the non-occurrence group (all P＜0.05). Multivariate regression analysis demonstrated that hypertension,elevated hs-cTnT, elevated Hcy, and increased 24 h SSD, dSSD and nSSD were influencing factors for CAS in elderly HFpEF patients (all OR＞1, all P＜0.05). The receiver operator characteristic (ROC) curve analysis showed that hypertension, hs-cTnT, Hcy,24 h SSD,dSSD, and nSSD all had certain predictive value, and the combined prediction had a higher value.Conclusion24 h SSD, dSSD, nSSD are closely related to CAS in elderly patients with HFpEF, and their elevated levels suggest an increased risk of CAS. Combined hypertension, elevated hs-cTnT and Hcy levels can further increase the risk. Combined detection of these indicators can significantly improve the early prediction of CAS.