In a target trial emulation study of 109,504 adults with newly diagnosed gout initiating urate-lowering therapy, achieving serum urate levels below 6 mg/dL within 12 months was associated with a lower 5-year risk of major adverse cardiovascular events compared with not achieving target levels. Patients who reached target urate levels had a weighted hazard ratio for major adverse cardiovascular events of 0.91 and an absolute 5-year event-free survival difference of 1.0 percentage point. Associations were stronger among patients achieving serum urate levels below 5 mg/dL and among those at high or very high baseline cardiovascular risk.