The metabolic syndrome, a group of conditions including obesity, hypertension, insulin resistance and dyslipidemia, is an important target in coronary heart disease (CHD) risk reduction. Many questions regarding CHD risk and pathophysiology, and optimal treatment of metabolic syndrome have been debated in recent years. These conditions individually increase CHD risk, and several lines of evidence suggest that the components, acting together synergistically, additionally raise an individual's risk of developing cardiovascular disease. Many think that insulin resistance is the key component linking the syndrome to the development of CHD from a pathophysiologic point of view; however, a chronic inflammatory state has also been implicated. New medications, such as the cannabinoid antagonists, are being tested as potential treatments for metabolic syndrome. How best to treat advanced coronary disease in patients with metabolic syndrome remains a major challenge.