Arterial hypertension in patients with metabolic cardiovascular syndrome (MS) has a number of features which are of great theoretical and practical significance. It has been shown that hypertension is the most frequent component of MS and chronologically follows abdominal obesity while clinical manifestations of atherosclerosis and carbohydrate metabolism disturbances develop much later. In addition, the disorders of hypothalamic-pituitary-adrenal axis contribute to the development of arterial hypertension in patients with abdominal obesity. Besides the abnormalities of central regulatory mechanisms, increased sympathetic tone, insulin resistance and hyperinsulinemia, functional state of adipose tissue is an established important factor for the development of systemic hypertension in patients with abdominal obesity, and in some cases the dysfunction of adipocytes, which can be genetically determined or acquired, may cause the whole cascade of MS. Search for the causes and mechanisms of arterial hypertension in patients with MS can help to find the possible targeted treatment and prevention of the disease.