ObjectivesTo investigate carotid intima‐media roughness (IMR) in hypertensive patients with normal carotid intima‐media thickness (IMT) using automatic identification software and the correlation between carotid IMR and risk factors.MethodsThis case‐control study comprised 61 hypertensive patients with normal carotid IMT and 51 control participants. Carotid IMR, carotid IMT, pulsed wave velocity (PWV), stiffness (β), and arterial compliance were determined by carotid ultrasound and image postprocessing using an automatic identification program and echo‐tracking analysis software.ResultsCarotid IMR, mean carotid IMT, maximum carotid IMT, β, and PWV in the hypertension group were higher than those in the control group (58.24 versus 34.61 μm, 641.17 versus 576.48 μm, 746.82 versus 640.55 μm, 9.42 versus 7.35, and 7.10 versus 5.86 m/s, respectively; P < .05), and arterial compliance was lower than that in the control group (0.70 versus 0.95 mm2/kPa; P < .05). Intima‐media roughness was correlated with maximum IMT, mean IMT, PWV, β, age, diagnosis of hypertension for greater than 1 year, and pulse pressure. Multivariate logistic regression showed that age, diagnosis of hypertension for greater than 1 year, and pulse pressure were influential factors for IMR in hypertensive patients, with odds ratios of 6.719 (95% confidence interval, 1.658–27.221; P = .008), 4.726 (95% confidence interval, 1.174–19.022; P = .029), and 3.998 (95% confidence interval, 1.033–15.466; P = .045), respectively.ConclusionsCarotid IMR and the elasticity index have important clinical importance in evaluating the risk of early atherosclerosis in hypertensive populations.