The metabolic syndrome (MS) is a clustering of cardiovascular risk factors. Current definitions of MS use hypertension, waist circumference, fasting glucose, triglyceride and HDL-cholesterol levels as defining variables. The prevalence of MS is increasing in our society due to lifestyle changes that result in decreased physical activity and increased body weight. Patients with MS have a three times greater risk of coronary heart disease and stroke, and a two to four times greater risk of dying from atherosclerotic coronary heart disease than those without MS. Imaging studies have shown an increased burden and progression of atherosclerosis. Also, MS patients seem to be more vulnerable to events at comparable levels of atherosclerosis. First-line treatment for MS is therapeutic lifestyle intervention, including exercise and weight reduction. Medical intervention strategies using blood pressure-lowering medication, statins, fibrates and metformin seem the most appropriate to date. The effects of thiazolidinediones on cardiovascular endpoints have not been studied to a large extent in the setting of MS. Evidence regarding risk assessment and optimal medical strategies will be an important aspect of vascular research in the coming years.