The insulin resistance syndrome comprises a typical cluster of cardiovascular risk factors and is predicted to increase dramatically over the next few decades. The disease process starts many years before the condition is clinically obvious and targets primarily the cardiovascular system. The pathogenesis involves a complex interplay between all the associated cardiovascular risk factors but endothelial dysfunction plays a major role. Management of these patients involves management of all the associated risk factors and should be aimed primarily at early detection and the prevention of vascular morbidity and mortality in the short and long term.