CONTEXT: Increased activity of the hypothalamic-pituitary-adrenal (HPA) axis may underlie the metabolic syndrome, but whether circulating cortisol levels predict cardiovascular end points is less clear. People with type 2 diabetes are at increased cardiovascular disease risk and thus are suitable to study associations of plasma cortisol with cardiovascular risk. OBJECTIVE: We aimed to assess whether altered HPA axis activity was associated with features of the metabolic syndrome and ischemic heart disease in people with type 2 diabetes. DESIGN AND SETTING: We conducted a cross-sectional cohort study in the general community, including 919 men and women aged 67.9 (4.2) yr with type 2 diabetes (the Edinburgh Type 2 Diabetes Study). INTERVENTION: We measured fasting morning plasma cortisol. MAIN OUTCOME MEASUREMENT: Associations between cortisol levels, features of the metabolic syndrome, obesity, and ischemic heart disease were determined. RESULTS: Elevated plasma cortisol levels were associated with raised fasting glucose and total cholesterol levels (P <0.001). These findings remained significant after adjustment for potential confounding factors (P <0.001). Elevated cortisol levels were associated with prevalent ischemic heart disease (>800 vs.