The aim of this study was to investigate whether long-term changes in traditional risk factors affect the progression of carotid atherosclerosis in a Chinese population. This study included 1590 individuals (aged 56.9 +/- 8.1 years) with no evidence of carotid plaque at baseline (2002). In 2007, these individuals completed the second risk factors survey and underwent carotid plaque measurement. The incidence of carotid plaque and the total plaque area of maximum plaques (TPA) were used to evaluate the progression of carotid atherosclerosis. In addition to baseline age, systolic blood pressure (SBP), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), triglyceride (TG), common carotid intima-media thickness (CIMT) and current smoking, a 5-year change in SBP was also associated with the incidence of carotid plaque (odds ratio = 1.01, 95% confidence interval: 1.01-1.02, P = 0.029). Furthermore, multiple linear regression analysis revealed that a 5-year change in SBP had a linear association with TPA after adjusting for baseline risk factors (standardized regression coefficient = 0.071, P = 0.014). TPA increased both by increasing baseline SBP and by a 5-year SBP change when adjusted for sex, baseline age, TC, HDL-C, CIMT and current smoking (P for trend <0.001 and 0.004). Our study demonstrates that a 5-year change in SBP is independently associated with the progression of carotid atherosclerosis in the Chinese population. These findings underline the importance of early detection and control of SBP for the prevention of atherosclerosis progression. The progression of atherosclerosis is not only associated with hypertension but can also progress silently with the development of SBP.