Background At present, the relationship among inflammatory markers [monocytes/HDL-c (MHR), neutrophils/HDL-c (NHR) and lymphocytes/HDL-c (LHR)] and long-term prognosis of coronary heart disease (CHD) is still unclear. Therefore, this study explores the relationship between inflammatory indicators and the risk of long-term major adverse cardiovascular events (MACE) in elderly patients with CHD. Methods A retrospective analysis was conducted on 208 elderly patients who underwent coronary angiography at Wuhan Fourth Hospital from August 2022 to August 2023. They were divided into the CHD group (N = 116) and control group (N = 92). Patients in the CHD group were followed up for 1 year and divided into the MACE group (N = 36) and the non-MACE group (N = 80) according to whether MACE occurred. Results In elderly patients, logistic regression analysis shows that MHR is an independent risk factor for CHD (OR = 3.050, 95% CI 1.318-1.772). ROC curve analysis found that MHR (AUC = 0.865, 95% CI 0.811-0.919, p < 0.001) is higher than NHR and LHR. In patients with CHD, the spearman analysis show that MHR is positively correlated with Gensini score (R = 0.266, p = 0.004). The logistic regression analysis found that MHR is independent risk factors for MACE (OR = 6.048, 95% CI 1.224-1.941, p = 0.002). ROC analysis showed that the critical value of MHR to predict MACE was 0.651, the sensitivity of 58.3% and specificity of 90.0% could predict MACE, and the AUC was 0.793 (95% CI 0.702-0.884, p < 0.001) is higher than LHR. Conclusion In elderly patients, MHR is an independent predictor of CHD and long-term MACE and is positively correlated with the severity of coronary artery lesions.