The inclusion of coronary heart disease (CHD) risk equivalents in the highest CHD risk category, in addition to the lowest low-density lipoprotein cholesterol (LDL-C) targets, has dramatically increased the number of persons eligible for highly effective risk reduction and lipid-lowering treatment. Two such high-risk groups are persons with diabetes and those with metabolic syndrome. These patients typically have a number of lipid and nonlipid risk factors that require aggressive intervention. In patients with diabetes, treatment with 3-hydroxy-3-methyglutaryl coenzyme A reductase inhibitors ("statins") to lower LDL-C levels and improve other lipid measures has been shown to produce protective benefits at least equal to those observed in nondiabetic patients. Although metabolic syndrome is not yet recognized as a CHD risk equivalent and use of Framingham risk scoring may not place some patients with the syndrome in the highest risk category, there is accumulating evidence that these patients are at very elevated risk and should be treated aggressively. Particular problems in risk assessment arise in immigrant groups such as South Asians, in whom traditional risk assessment may be inaccurate. In this article, Dr Deedwania examines the clinical evidence regarding cardiovascular risk associated with diabetes and metabolic syndrome and discusses current therapeutic options. Two case reports are presented, followed by roundtable discussions among the contributors to this Special Report.