Background: Rotational atherectomy (RA) is an important technique for the management of severe coronary calcification. However, optimal rotational speed is yet to be defined. Methods: A total of 372 coronary heart disease (CHD) patients were retrospectively analyzed between February 2017 and January 2022. The patients were divided into four groups based on the maximum RA speed: group 1 (150,000 rpm, 76 cases), group 2 (150,000 rpm, 156 cases), group 3 (160,000 rpm, 90 cases) and group 4 (\ge170,000 rpm, 50 cases). The outcomes analyzed were procedural complications, six-months major cardiovascular and cerebrovascular events (MACCE) and chronic heart failure. Results: Patients in group 4 had a higher incidence of slow flow during the RA operation (p = 0.025). There was no significant difference in other complications among the four groups, as well as six-month MACCE. After adjusting for confounding factors, increase in rotational speed led to a higher probability of slow flow (p for non-linearity = 0.131; adjusted model) and MACCE (p for non-linearity = 0.183; adjusted model). Logistic regression analysis showed that rotational speed was a predictor of slow flow during RA operation (OR = 1.25, 95% CI: 1.05~1.49, p = 0.01). Moreover, the analysis demonstrated that individuals with lower rotational speed (150,000 rpm) were at 230% higher risk of vasospasm compared with a higher rotational speed (160,000 rpm) (OR = 3.3, 95% CI: 1.08~10.09, p = 0.036). Conclusions: CHD patients treated with a rotational speed of \ge170,000 rpm had a higher risk of slow flow after RA. Rotational speed is an independent risk factor for slow flow in CHD patients. Moreover, a rotational speed of 150,000 rpm was associated with a higher risk of vasospasm compared with rotational speed of 160,000 rpm. There was no significant difference in six-month outcomes in comparison to elective CHD patients with different rotational speeds, and the probability of MACCE was intensified with increase in rotational speed.