Patients with severe mental illness (SMI), including schizophrenia and bipolar disorder, have a significantly higher risk of cardiovascular disease and mortality compared to the general population, often due to sudden cardiac death. This review addresses the complex relationship between SMI and cardiovascular risk, explores disparities in cardiovascular care, and proposes targeted interventions to improve cardiovascular health in these patients. SMI is associated with an adverse cardiovascular risk profile due to biological factors like chronic inflammation, patient factors such as excessive smoking, and healthcare system factors like stigma and discrimination. Patients with SMI have a 47% lower likelihood of undergoing invasive coronary procedures and lower rates of prescribed secondary prevention medications compared to the general population. Conventional risk prediction models are inadequate for SMI patients, as cardiovascular disease and mortality are not fully driven by traditional risk factors. SMI-specific risk prediction models and clinical tools like ECG and echocardiogram are necessary for accurate assessment and management. The review emphasizes the need for differentiated cardiovascular care, addressing factors contributing to excess cardiovascular risk, reconsidering risk stratification, and implementing multidisciplinary care models to improve cardiovascular health and long-term outcomes in patients with SMI. Key clinical recommendations include early hypertension screening, aggressive lipid management, diabetes care, smoking cessation, and integrated healthcare approaches. Multidisciplinary care models combining mental health and cardiovascular care are essential for addressing the unique challenges faced by patients with SMI and improving their cardiovascular health and long-term outcomes.Patients with severe mental illness (SMI), including schizophrenia and bipolar disorder, have a significantly higher risk of cardiovascular disease and mortality compared to the general population, often due to sudden cardiac death. This review addresses the complex relationship between SMI and cardiovascular risk, explores disparities in cardiovascular care, and proposes targeted interventions to improve cardiovascular health in these patients. SMI is associated with an adverse cardiovascular risk profile due to biological factors like chronic inflammation, patient factors such as excessive smoking, and healthcare system factors like stigma and discrimination. Patients with SMI have a 47% lower likelihood of undergoing invasive coronary procedures and lower rates of prescribed secondary prevention medications compared to the general population. Conventional risk prediction models are inadequate for SMI patients, as cardiovascular disease and mortality are not fully driven by traditional risk factors. SMI-specific risk prediction models and clinical tools like ECG and echocardiogram are necessary for accurate assessment and management. The review emphasizes the need for differentiated cardiovascular care, addressing factors contributing to excess cardiovascular risk, reconsidering risk stratification, and implementing multidisciplinary care models to improve cardiovascular health and long-term outcomes in patients with SMI. Key clinical recommendations include early hypertension screening, aggressive lipid management, diabetes care, smoking cessation, and integrated healthcare approaches. Multidisciplinary care models combining mental health and cardiovascular care are essential for addressing the unique challenges faced by patients with SMI and improving their cardiovascular health and long-term outcomes.