Individuals with bipolar disorder experience twice the cardiovascular mortality expected from general population estimates. The metabolic syndrome is more common in those with bipolar disorder, with a prevalence ratio of 1.6, and includes many traditional cardiovascular risk factors, which may explain much of the elevated risk. Manic symptom burden also predicts cardiovascular mortality, begging questions regarding other explanations for elevated cardiovascular risk. Ultimately, the mechanisms that lead to elevated cardiovascular risk in bipolar disorder are complex and potentially involve behavior, treatment, access to quality health care, and underlying pathophysiology. Much remains unknown about the etiology of any mechanisms inherent to illness or, for that matter, treatment effects. Addressing access and health behaviors can mitigate risk for individuals with bipolar disorder. Recent evidence indicates that psychiatrists are becoming aware of the vascular risk associated with bipolar disorder, although further education will improve monitoring and subsequent outcomes.