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Background: The cutoff of abdominal circumference for metabolic syndrome (MS) defined by the Bureau of Health Promotion (BHP) of Taiwan for Taiwanese (men, 90cm; women, 80cm) and by the International Diabetes Federation (IDF) for Japanese (men, 85cm; women, 90cm) differs. This study aimed to examine the impact of this difference on the prevalence of MS and the impact of an MS diagnosis on the projected risk of stroke in hypertensive Taiwanese. Methods: MS was examined in a sample of 3,472 hypertensive patients (aged 55–80 years; 1,709 women) across Taiwan. The 10-year probability of stroke estimated from the Framingham equation was compared between MS and non-MS patients. Results: The prevalence of MS using the BHP criteria was 59.2% using the BHP criteria (95% confidence interval, CI, 57.6–60.8%; men, 52.5%; women, 66.1%) and 48.9% by the IDF criteria (95% CI, 47.2–50.5%; men, 61.3%; women, 36.1%). Both criteria showed that, compared with non-MS, MS has higher predicted 10-year probability of stroke (BHP, 0.153 ± 0.115 vs. 0.133 ± 0.105; IDF, 0.159 ± 0.109 vs. 0.132 ± 0.112; both p < 0.001) because of the difference in women (BHP, 0.143 ± 0.124 vs. 0.102 ± 0.091; IDF, 0.147 ± 0.121 vs. 0.118 ± 0.110; both p < 0.001) rather than men (BHP, p = 0.21; IDF, p = 0.29). Conclusion: Both criteria demonstrate that MS is highly prevalent in elderly hypertensive patients in Taiwan. Additionally in women, but not men, the predicted probability of stroke is higher in MS than in non-MS patients. The diagnosis of MS is potentially useful for identifying elderly hypertensive females with an elevated risk of stroke in Taiwan.