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To prospectively analyze the relationship of baseline blood pressure with 10 years progression of carotid atherosclerosis.Blood pressure and carotid ultrasonography along with other cardiovascular risk factors were measured first at baseline in 2002 and again in 2012 in a Chinese population of 906 men and women, aged 42 to 73 years old, in 2002. We used multiple logistic regression and general linear regression to analyze the relationship of baseline blood pressure and the risk of developing carotid new plaques and the increase in total plaque area and intima media thickness (IMT).Compared with participants with systolic blood pressure (SBP) < 120 mmHg at baseline, the odds ratio of developing new carotid plaque in the next 10 years (defined as number of plaque at resurvey > that at baseline) was 1.49(95%CI: 1.04–2.12) for those with SBP at 120–139 mmHg, 1.76 (1.14–2.71) for those with SBP at 140–159 mmHg, and 2.51 (1.35–4.64) for those with SBP > = 160 mmHg respectively, after adjusting for age, sex, smoking, LDL-c, glucose, and body mass index (BMI). Similar trend was observed between baseline SBP and 10-year increase in plaque area (p < 0.001), but not in IMT (p = 0.472). The similar trends were observed for baseline diastolic blood pressure but only statistically significant for 10-year increase in IMT in a U-shape (p = 0.013).Higher SBP was found significantly associated with development of new carotid plaque and increase in carotid plaque area, indicating SBP plays an important role in the development of atherosclerosis.