This review addresses the complex relationship between severe mental illness (SMI) and cardiovascular risk, highlighting disparities in cardiovascular care pathways and proposing targeted interventions to improve cardiovascular health in patients with SMI. Patients with SMI, including schizophrenia and bipolar disorder, have a significantly reduced life expectancy due to an increased risk of cardiovascular disease, often leading to sudden death. The review discusses the multifactorial nature of this increased risk, involving biological factors such as chronic inflammation, patient factors like excessive smoking, and healthcare system factors such as stigma and discrimination. It emphasizes the need for differentiated cardiovascular care, including early risk prediction, tailored primary prevention strategies, and multidisciplinary care models. The review also highlights the underutilization of standard cardiovascular medications and the importance of addressing social deprivation and poor self-care in these patients. Finally, it calls for further research to better understand the complex interplay between mental health and cardiovascular disease, aiming to develop more effective interventions to improve long-term outcomes in patients with SMI.This review addresses the complex relationship between severe mental illness (SMI) and cardiovascular risk, highlighting disparities in cardiovascular care pathways and proposing targeted interventions to improve cardiovascular health in patients with SMI. Patients with SMI, including schizophrenia and bipolar disorder, have a significantly reduced life expectancy due to an increased risk of cardiovascular disease, often leading to sudden death. The review discusses the multifactorial nature of this increased risk, involving biological factors such as chronic inflammation, patient factors like excessive smoking, and healthcare system factors such as stigma and discrimination. It emphasizes the need for differentiated cardiovascular care, including early risk prediction, tailored primary prevention strategies, and multidisciplinary care models. The review also highlights the underutilization of standard cardiovascular medications and the importance of addressing social deprivation and poor self-care in these patients. Finally, it calls for further research to better understand the complex interplay between mental health and cardiovascular disease, aiming to develop more effective interventions to improve long-term outcomes in patients with SMI.