Metabolic syndrome (MS) is associated with excess cardiovascular risk above and beyond the contribution of traditional risk factors. It is a proinflammatory and prothrombotic condition associated with underlying insulin resistance. Hypertension and hyperlipidemia in the setting of MS are also associated with excess cardiovascular risk, as is the development of new onset diabetes during the course of therapy. Although impaired fasting glucose and impaired glucose tolerance (IGT) both predict the development of diabetes mellitus, IGT more strongly predicts CV events because it is associated with a greater degree of insulin resistance. Early recognition and aggressive lifestyle interventions are the cornerstones of treatment, with aggressive pharmacologic therapy introduced when appropriate. It is expected that future studies will more clearly define the early use of insulin-sensitizing agents in MS.