Abstract-Insulin resistance is characteristic of obesity, type 2 diabetes, and components of the cardiometabolic syndrome, including hypertension and dyslipidemia, that collectively contribute to a substantial risk for cardiovascular disease. Metabolic actions of insulin in classic insulin target tissues (eg, skeletal muscle, fat, and liver), as well as actions in nonclassic targets (eg, cardiovascular tissue), help to explain why insulin resistance and metabolic dysregulation are central in the pathogenesis of the cardiometabolic syndrome and cardiovascular disease. Glucose and lipid metabolism are largely dependent on mitochondria to generate energy in cells. Thereby, when nutrient oxidation is inefficient, the ratio of ATP production/oxygen consumption is low, leading to an increased production of superoxide anions. Reactive oxygen species formation may have maladaptive consequences that increase the rate of mutagenesis and stimulate proinflammatory processes. In addition to reactive oxygen species formation, genetic factors, aging, and reduced mitochondrial biogenesis all contribute to mitochondrial dysfunction. These factors also contribute to insulin resistance in classic and nonclassic insulin target tissues. Insulin resistance emanating from mitochondrial dysfunction may contribute to metabolic and cardiovascular abnormalities and subsequent increases in cardiovascular disease. Furthermore, interventions that improve mitochondrial function also improve insulin resistance. Collectively, these observations suggest that mitochondrial dysfunction may be a central cause of insulin resistance and associated complications. In this review, we discuss mechanisms of mitochondrial dysfunction related to the pathophysiology of insulin resistance in classic insulin-responsive tissue, as well as cardiovascular tissue. (Circ Res. 2008;102:401-414.)Key Words: mitochondrial dysfunction Ⅲ insulin resistance Ⅲ cardiovascular disease T here are at least 47 million people in the United States who have the cardiometabolic syndrome, a precursor to diabetes and subsequent cardiovascular complications. 1 Furthermore, the development of insulin resistance, the cardinal feature of the cardiometabolic syndrome, is associated with increased tissue renin-angiotensin system activity and increasingly appears to be a nexus between components of the syndrome. 2,3 The metabolic actions of insulin maintain glucose homeostasis by promoting glucose uptake in skeletal muscle and suppressing glucose production in the liver. Insulin resistance is typically defined as decreased sensitivity to these metabolic actions of insulin. Insulin-resistant individuals are at higher risk of developing type 2 diabetes mellitus (T2DM) and cardiovascular disease compared with Original received October 12, 2007; revision received December 17, 2007; accepted January 9, 2008 Figure 2). 5-7 Furthermore, we and others have shown that blockade of the AT 1 R reduces oxidative stress and mitochondrial structure and functional abnormalities in rodent models of excessi...