There are many evidence that links cardiovascular (CV) complications to primary hyperparathyroidism (PHPT). However, these CV complications have never been considered an indication for surgical management of PHPT, and even some studies showed that in those that have surgical treatment, there is no evidence of reversibility of the CV complications. Despite the reasonable explanation of the underlined mechanisms involved in these complications in the literature that prove the increased CV associations, there are some conflicting data that showed no or even reduced associations and this has been a matter of debate for decades. The CV complications reported to have associations with PHPT include cardiac (left ventricular remodeling, coronary vascular disease, calcifications), vascular including hypertension (HTN), atherosclerosis, cardiometabolic complications including insulin resistance, diabetes mellitus, and CV mortality. This article reviewed the strength of current evidence and the author’s stand on whether it is worth including in the guideline as an indication for current treatment.