Background <p>The efficacy and safety of the combination therapy of Shanhuang Jiangzhi tablets and atorvastatin in treating primary hyperlipidemia and carotid atherosclerosis remain unclear and require further investigation.</p> Materials and methods <p>A retrospective cohort study was conducted using the medical records of the neurology wards from 1 January 2014 to 30 June 2022. Patients were divided into observation and control groups based on inclusion and exclusion criteria. The control group received atorvastatin calcium tablets at a dose of 20&#xa0;mg per day, whereas the observation group received the same dose of atorvastatin plus Shanhuang Jiangzhi tablets at 2.4&#xa0;g per day. The treatment period for both groups was 2 years. Blood lipid profiles and carotid ultrasound indicators were compared before and after treatment. All the data were statistically analysed using SPSS 26.0.</p> Results <p>This study included 319 atherosclerosis patients, with 162 in the observation group (average age 62.84 ± 11.90 years, 44.4% men) and 157 in the control group (average age 62.62 ± 10.33 years, 52.2% men). No significant differences were found in baseline characteristics between the two groups (<i>p</i> &gt; 0.05). Following treatment, significant reductions in total cholesterol (4.38 ± 1.07 vs. 4.71 ± 1.11) and low-density lipoprotein cholesterol levels (2.78 ± 0.80 vs. 3.11 ± 0.92) were observed in the observation group compared with the control group (<i>p</i> &lt; 0.05). Additionally, improvements in the carotid intima-media thickness (IMT) (1.63 ± 0.09 vs. 1.80 ± 0.05) and plaque scores (4.06 ± 0.26 vs. 4.17 ± 0.29) were more pronounced in the observation group (<i>p</i> &lt; 0.05).</p> Conclusion <p>This study investigated the use of Shanhuang Jiangzhi tablets combined with atorvastatin calcium for carotid atherosclerosis, offering effective options for traditional Chinese medicine in managing atherosclerosis and hyperlipidaemia.</p>