Abstract Introduction There is increasing evidence that both hyperuricemia and gout increase the risk of cardiovascular morbidity and mortality. Whether urate crystal precipitation confers a particular risk above what is already inherent in having hyperuricemia is not well established. We conducted this cohort study to establish whether the presence of monosodium urate crystal precipitation per se is associated with increased risk of cardiovascular diseases among hyperuricemic patients. Methods We identified hyperuricemic individuals who had joint fluid examinations for urate crystals. Individuals with intra-articular urate crystals were matched by propensity score to individuals without crystals and compared with respect to a composite cardiovascular endpoint. Included in the propensity score model were potential confounders retrieved from four different health care registries. Results We identified 862 hyperuricemic patients having urate crystal examination. After propensity score matching, we could include 317 patients with urate crystals matched 1:1 to patients without urate crystals. We found no difference between the two groups with respect to cardiovascular outcomes (hazard ratios = 0.86; 95 % confidence interval (CI) 0.52 - 1.43) or death (hazard ratio 0.74; CI 0.45 - 1.21). Conclusion The presence of urate crystal precipitations does not seem to confer a particular cardiovascular risk in hyperuricemic patients.