Efforts are being made to identify cardiovascular (CV) risk factors (RF) and intervene in high-risk subjects aiming to reduce CV mortality. Disorders grouped under the metabolic syndrome (MS), linked by insulin resistance (IR), confer high CV risk due to the cluster of glucose intolerance, hypertension, elevated triglycerides and low HDL-cholesterol leveis in addition to several recently described RF. Hyperinsulinemia is considered an independent RF; central obesity is associated with major RF independently of BMI. High visceral fat lipolytic activity results in overproduction of free fatty acids and metabolic consequences, characterizing the IR state. Association of microalbuminuria with hypertension, triglyceride and fibrinogen leveis suggested a role in predicting CV disease. It should be considered a marker of generalized endothelial dysfunction. Hypofibrinolysis due to fibrinogen and PAI-1 elevations, induced by the IR state, facilitates atherothrombosis in patients with MS. The thrombìn activator fibrinolysis inhibitor is also independently associated with markers of obesity, glycated hemoglobin and IR. Hyper-homocystinemia is associated wíth deleterious vessel effects and seems to be result from endothelial damage, chronic inflammatory status and kidney impairment. C-reactive protein and adiponectin - sensitive markers of inflammation - are also associated with IR. Endothelin-1 can lead to MS disorders and increased production might reflect endothelial damage caused by IR. In summary, patients with MS are at the highest risk of dying from CV events. Interventional trials directed to components of MS and also to increase insulin sensitivity are needed to establish the prognostic impact in CV morbidity and mortality.