We explored the associations between lipoprotein-associated phospholipase A2 (Lp-PLA2) level and carotid atherosclerosis with all phenotypes and cardiovascular disease (CVD) events in Chinese older adults. A total of 1257 adults aged ≥55 years who were free of CVD were enrolled in this cohort study. Lipoprotein-associated phospholipase A2 level was evaluated in 3 categories: Lp-PLA2 < 175, 175≤ Lp-PLA2 < 223, and Lp-PLA2 ≥ 223 ng/mL. The highest level of Lp-PLA2 was independently associated with common carotid artery intima-media thickening (≥1.0 mm; odds ratio [OR]: 1.60, 95% confidence interval [CI]: 1.14-2.26) and carotid plaque (OR: 1.42, 95% CI: 1.01-1.99) in individuals without carotid artery stenosis. At the end of the 5-year follow-up, after adjustment for CVD risk factors and carotid atherosclerosis status, Lp-PLA2 had remained an independent predictor for myocardial infarction (MI; hazard ratio [HR]: 1.90, 95% CI: 1.02-3.55) and CVD death (HR: 1.78, 95% CI: 1.02-3.13). However, no association was found with stroke. Therefore, elevated Lp-PLA2 level in the older adults studied was associated with an increased risk of carotid atherosclerosis and MI and CVD mortality. Lipoprotein-associated phospholipase A2 assessment might be used for MI and CVD death risk prediction.