Epidemiologic studies have shown a variety of metabolic abnormalities to be risk factors for coronary heart disease. Many of these metabolic risk factors coexist and may have as a common denominator the presence of insulin resistance and hyperinsulinemia. Indeed, clinical studies have demonstrated relationships among blood pressure levels, plasma insulin, fibrinogen, plasminogen activator inhibitor, factor VIII, triglycerides, and total cholesterol levels and other metabolic risk factors. Individuals with hyperinsulinemia generally have low levels of high-density lipoprotein, plasminogen activators, and endothelial relaxing factors as well. New pharmacologic and hygienic treatment strategies that enhance insulin sensitivity and help correct lipoprotein metabolism and other metabolic abnormalities will be critical in maximizing coronary risk reduction in persons with hypertension, diabetes mellitus, or a family history of premature coronary heart disease.