Most studies point to an increased prevalence of metabolic syndrome (MS) and an increased risk of coronary heart disease (CHD) in schizophrenia patients with MS. The aims of this study were to compare the prevalence of MS in schizophrenia patients with the general population, to explore the clinical correlates and predictors of MS and to evaluate the risk for CHD within 10 years. Consecutive 319 patients, aged 18–75 years, with a diagnosis of schizophrenia according to the DSM-IV were enrolled. The ATP-III, the ATP-IIIA and the IDF criteria were used to define MS. 10-year risk of CHD events was calculated with the Framingham score. One hundred nine (34.2%) patients met the ATP-III criteria, 118 (37%) the ATP-IIIA and 133 (41.7%) the IDF criteria for MS. Patients with MS were older, had a later onset of illness and an older age at first hospitalization. The prevalence of MS in schizophrenia patients was higher from the general population only within the 20–29 age group. Patients with MS had a higher age and sex-corrected 10-year risk of CHD events. The only predictor of MS was the age of illness onset. In conclusion, countries where the general population prevalence of MS is already too high, schizophrenia patients younger than 30 years of age might be under higher risk of morbidity and mortality related with MS. This study points to the necessity for aggressive interventions to correct MS in schizophrenia as early as possible, within the first 10 years of post detection.