BACKGROUND: It is not known whether the metabolic syndrome detects further individuals at high risk of death from cardiovascular disease (CVD), beyond those identified by a conventional cardiovascular risk score. DESIGN: A prospective study. METHODS: A total of 2790 men without diabetes, aged 50-69 years from seven population-based European cohorts participating in the DECODE Study, were followed for CVD mortality over 10 years. RESULTS: Some 51% of the men had an estimated 10-year risk of fatal CVD under 5%, using the European SCORE project equation, and 22% of them had the metabolic syndrome, as defined by the National Cholesterol Education Program Adult Treatment Panel III. In the low-risk men, the hazards ratio for fatal CVD, after adjusting for age and study centre, was 2.71 (1.33-5.51) for men with the syndrome (P<0.01) compared with men without the syndrome. A large waist circumference (>102 cm) carried an odds ratio of 2.24 (1.05-4.76) in the low CVD risk men. CONCLUSIONS: Men with a low cardiovascular risk score and the metabolic syndrome had a significantly higher risk of fatal CVD than those without the syndrome. The use of the metabolic syndrome in clinical practice is thus justified in men, but waist circumference provided a simpler diagnostic tool with similar fatal CVD risk in these low-risk men. A large waist circumference could be used for prescreening, and could be included in CVD risk scores.