Objectives The aim of this study was to investigate the effects of acupuncture on major adverse cardiovascular events (MACE), myocardial infarction, stroke and death in hypertensive patients taking anti-hypertensives. Methods Using the Korean National Health Insurance Service—National Sample Cohort (NHIS-NSC) database, this study identified 59,370 patients taking anti-hypertensives who had been diagnosed with hypertension between 2003 and 2006. They were divided into acupuncture and non-acupuncture groups. The follow-up period ended with the diagnosis of myocardial infarction, stroke or death. After propensity score matching (PSM), there were 18,011 patients each in the non-acupuncture and acupuncture groups. We calculated the incidence rate, hazard ratio (HR) and 95% confidence interval (CI) for MACE, myocardial infarction, stroke and death in patients with hypertension using a stratified Cox proportional hazard model. In addition, secondary outcome analyses for stroke and cardiovascular mortality were performed. Results After PSM, the HRs for MACE (0.83, 95% CI 0.80–0.86), all-cause mortality (0.73, 95% CI 0.70–0.76) and myocardial infarction (0.85, 95% CI 0.79–0.92) were significantly lower in the acupuncture group than in the non-acupuncture group. Moreover, the HRs for stroke-related mortality, hemorrhage stroke–related mortality, ischemic stroke–related mortality, ischemic heart disease–related mortality and circulatory system disease–related mortality were significantly lower in the acupuncture group than in the non-acupuncture group. Conclusion This observational study with long-term follow-up extends the evidence base in support of the effectiveness of acupuncture for the management of hypertension and potentially reduce the burden of cardiovascular disease.