Recent evidence indicates that long-term visit-to-visit blood pressure variability (BPV) may be an independent cardiovascular risk predictor. The implication of this variability in hypertension clinical practice is unclear. BPV as average real variability (ARV) was calculated in 14 522 treated patients with hypertension in 4 time frames: year 1 (Y₁), years 2 to 5 (Y_2–5), years 5 to 10 (Y_5–10), and years >10 (Y₁₀₊) from first clinic visit. Cox proportional hazards models for cause-specific mortality were used in each time frame separately for long-term BPV, across time frames based on ultra long–term BPV, and within each time frame stratified by mean BP. ARV in systolic blood pressure (SBP), termed ARV_SBP, was higher in Y₁ (21.3±11.9 mm Hg) in contrast to Y_2–5 (17.7±9.9 mm Hg), Y_5–10 (17.4±9.6 mm Hg), and Y₁₀₊ (16.8±8.5 mm Hg). In all time frames, ARV_SBP was higher in women (P<0.01) and in older age (P<0.001), chronic kidney disease (P<0.01), and prevalent cardiovascular disease (P<0.01). Higher long-term and ultra long–term BPV values were associated with increased mortality (all-cause, cardiovascular, and noncardiovascular mortality; P for trend, <0.001). This relationship was also evident in subgroups with mean SBP<140 mm Hg in all time frames. Monitoring BPV in clinical practice may facilitate risk reduction strategies by identifying treated hypertensive individuals at high risk, especially those with BP within the normal range.