AIMS/BACKGROUND: Statins are first-line therapy for atherosclerotic cardiovascular disease (ASCVD), but their differential effects on glucose metabolism, particularly in the elderly, remain a clinical concern. This study aimed to compare the effects of pitavastatin versus atorvastatin on glucose metabolism in elderly patients with ASCVD. METHODS: In this retrospective cohort study conducted at Public Health Clinical Center Affiliated to Shandong University between January 2022 and December 2023, 126 elderly ASCVD patients aged ≥60 years were included and allocated to either the pitavastatin group (4 mg/day, n = 58) or the atorvastatin group (20 mg/day, n = 68). Fasting blood samples were collected at baseline and after 12 months of treatment to measure lipid profiles, glucose metabolism parameters, liver function, and renal function. RESULTS: After treatment, the pitavastatin group demonstrated significantly higher levels of high-density lipoprotein cholesterol (HDL-C) (1.41 ± 0.30 mmol/L vs. 1.26 ± 0.28 mmol/L, p = 0.005). Regarding glucose metabolism, the pitavastatin group showed lower fasting plasma glucose (5.85 ± 0.70 mmol/L vs. 6.19 ± 0.85 mmol/L, p = 0.018) and glycated hemoglobin (6.10 ± 0.42% vs. 6.33 ± 0.51%, p = 0.009). No cases of new-onset diabetes were detected in the pitavastatin group, as compared to the 10.29% rate observed in the atorvastatin group. Multivariate logistic regression analysis confirmed pitavastatin as a protective factor against new-onset diabetes (odds ratio = 0.212, p = 0.018). CONCLUSION: Compared with atorvastatin, pitavastatin may be associated with better glycemic outcomes and a lower risk of new-onset diabetes in elderly ASCVD patients, supporting its consideration in clinical practice where glycemic control is a concern.