The metabolic syndrome "Reloaded". MetS (Syndrome X) "reloaded" is a unique clustering of clinical syndromes and metabolic derangements. Reaven initially described the MetS in 1988. He initially discussed the four major determinants consisting of: I. Hypertension. II. Hyperinsulinemia. III. Hyperlipidemia (Dyslipidemia of elevated VLDL – triglycerides, decreased HDL-cholesterol, and elevated small dense atherogenic LDL-cholesterol). IV. Hyperglycemia or impaired glucose tolerance, impaired fasting glucose, or even overt T2DM and the central importance of insulin resistance and hyperinsulinemia. The important association of polycystic ovary syndrome (PCOS), hyperuricemia, fibrinogen, hsCRP, microalbuminuria, PAI-1, and more recently reactive oxygen species (ROS), NASH, and the damaging oxidative potential of Hcy and endothelial dysfunction have all contributed to a better understanding of this complicated clustering phenomenon. ROS, and those with a white background: Hyperuricemia, microalbuminuria, hyperhomocysteinemia, highly sensitive CRP, indicate the newer additions giving rise to the new terminology: Metabolic Syndrome Reloaded.