Hypertension remains the single most prevalent modifiable risk factor for cardiovascular disease globally, contributing to an estimated 10.4 million deaths annually and accounting for a disproportionate share of the cardiovascular disease burden across European populations. Despite substantial advances in antihypertensive pharmacotherapy, rates of blood pressure control remain suboptimal in most European countries, with surveys indicating that fewer than 40 percent of hypertensive individuals achieve the European Society of Cardiology recommended target of below 130/80 mmHg. This prospective multi-centre cohort study enrolled 6,248 hypertensive adults aged 40–80 years across twelve cardiology clinics in France, Poland, Greece, and Sweden, following participants for five years to characterise major adverse cardiac event (MACE) outcomes, blood pressure trajectory, and modifiable risk factor burden.A structured cardiovascular risk reduction intervention combining intensified antihypertensive pharmacotherapy, lifestyle modification counselling, and telemedicine-supported home blood pressure monitoring was tested against standard care in a randomised sub-cohort (n=6,248; 3,124 per arm). The intervention arm achieved a mean systolic blood pressure reduction of 34.0 mmHg from baseline (158.4 to 124.4 mmHg) compared to 6.0 mmHg in the control arm. Five-year MACE-free survival was significantly higher in the intervention arm (83.9% vs. 72.6%; HR=0.68, 95% CI 0.58–0.79, p<0.001). Multivariable regression identified age above 65, smoking, diabetes, and physical inactivity as the strongest independent predictors of MACE outcomes.