This study was conducted to evaluate the association of metabolic syndrome with angiographically significant coronary artery disease (CAD). The study population included a sample of 150 consecutive individuals with no history of CAD who underwent coronary angiography because of chest pain. Results showed that metabolic syndrome prevalence, identified according to the clinical criteria of NCEP-ATP III, was 61.3% in this group of patients. Moreover, the presence of metabolic syndrome was associated with a 2-fold higher CAD prevalence compared to those without metabolic syndrome, but this association was attenuated [odds ratio (OR)=1.770, 95% CI: 0.872-3.594] after adjusting for Framingham risk score. When stratifying individuals according to 10-year CAD risk with Framingham risk score, metabolic syndrome was significantly associated with CAD in individuals with low 10-year CAD risk (OR=4.577, 95% CI: 1.216-17.223). Including metabolic syndrome together with its own components into the same multivariate model revealed that only impaired fasting glucose was independently associated with angiographically significant CAD and that metabolic syndrome was not an independent determinant of angiographically significant CAD prevalence. These findings suggest that metabolic syndrome was associated with CAD only in individuals with low 10-year CAD risk.