Objective To study the predictive efficiency of carotid intima-media thickness (IMT) combined with thyroid-related hormones levels on the risk of ischemic stroke in elderly patients with coronary heart disease (CHD). Methods Totally 120 elderly patients with CHD from November 2022 to November 2024 were retrospectively selected. The clinical data of patients were collected, including general clinical data, carotid color Doppler ultrasound detection indicators (carotid IMT, carotid stenosis degree) and thyroid function detection indicators ［serum free triiodothyronine (FT3), serum free thyroxine (FT4), thyroid stimulating hormone (TSH), serum total triiodothyronine (TT3), serum total thyroxine (TT4)］. According to whether the patients were complicated with ischemic stroke, they were divided into stroke group (n=52) and non-stroke group (n=68). Univariate analysis was used to compare the differences in clinical data between groups. Multivariate Logistic regression model was adopted to analyze the association between carotid IMT and thyroid-related hormones and onset of stroke in patients with CHD. Receiver operating characteristic curve was used to evaluate the predictive efficiency of carotid IMT combined with thyroid-related hormones on the risk of stroke in CHD patients. Results There were no differences in general clinical data and TT3 and TT4 between groups （P＞0.05）, and IMT, carotid stenosis degree, TSH in the stroke group were higher while FT3 and FT4 was lower compared to the non-stroke group. IMT, FT3, FT4, TSH and carotid stenosis degree were associated with the risk of stroke. The increases of IMT, TSH and carotid stenosis degree were risk factors for stroke, and the increase of FT3 was a protective factor for stroke. The sensitivities of IMT, FT3 and TSH alone and in combination in predicting the risk of stroke were 0.731, 0.769, 0.673 and 0.981, and the specificities were 0.574, 0.912, 0.956 and 0.897, and the Youden indexes were 0.304, 0.681, 0.629 and 0.878, and the areas under the curves were 0.662, 0.903, 0.878 and 0.976 respectively. Conclusion The changes in IMT, FT3 and TSH hormone levels in elderly patients with coronary heart disease are related to the risk of ischemic stroke. The combined predictive efficacy of the three is good, which is helpful to optimize relevant preventive measures and improve the prognosis of patients