Background: Existing research has shown that retinol binding protein (RBP4) has an impairing effect on arterial elasticity and induces insulin resistance, but the clinical value of RBP4 in patients with coronary heart disease (CHD) combined with type 2 diabetes mellitus (T2DM) has not been investigated. This study sought to compare the complexity of coronary artery lesions and coronary artery elasticity between patients with CHD combined with T2DM and those with CHD without T2DM, analyze the risk factors affecting coronary artery elasticity, and investigate the value of RBP4 in assessing coronary artery elasticity in patients with CHD and T2DM. Methods: A total of 130 patients with confirmed CHD were consecutively enrolled, including 38 patients with CHD combined with T2DM and 92 patients with CHD without T2DM. Basic clinical data, laboratory findings, coronary angiography and intravascular ultrasound (IVUS) imaging data, and Gensini scores and coronary artery elasticity parameters were calculated in both groups. Elasticity parameters included: stiffness parameter (\beta), pressure-strain elastic modulus (E{}_{\text{p}}), distensibility coefficient (DC), and compliance coefficient (CC). Multiple linear regression equations were established with elasticity parameters as dependent variables to explore the factors influencing coronary artery elasticity parameters in patients within the two groups. Results: Compared with patients in the CHD without T2DM group, patients in the CHD combined with T2DM group had higher RBP4 levels, Gensini scores, \beta and E{}_{\text{p}} values, and lower DC and CC values. Linear regression analysis showed that Gensini score increased with higher \beta and E{}_{\text{p}} values and decreased with higher DC and CC values. In all patients in the CHD and CHD combined with T2DM groups, RBP4 was an independent risk factor for \beta values after correction for confounders by multiple linear regression analysis, whereas in patients in the CHD without T2DM group, the effect of RBP4 on \beta values was not statistically different. Conclusions: RBP4 was an independent risk factor of coronary artery elasticity in CHD patients with T2DM and in overall CHD patients, but it did not affect coronary artery elasticity in CHD patients without T2DM.