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Angiotensin II stimulates intraplaque hemorrhage in animal models, and the angiotensin system is highly regulated by vitamin D. The authors' purpose was to determine whether low vitamin D levels predict carotid intraplaque hemorrhage (IPH). In this cross-sectional study, 65 patients with carotid disease underwent carotid MR imaging and blood draw. Systemic clinical confounders and local lumen imaging markers were recorded. They performed multivariable Poisson regression by using generalized estimating equations to account for up to 2 carotid arteries per patient and backward elimination of confounders. The authors found that low vitamin D levels (<30 ng/mL) were a significant predictor of MRI-detected IPH, along with plaque thickness. They conclude that vitamin D insufficiency was associated with both the presence and volume of carotid IPH in patients with carotid atherosclerosis and that these results link low vitamin D levels with plaque vulnerability.