Another result of all that heat is the fan has to work very hard to expel all that hot air, and a hard-working fan means a noisy fan. When not being taxed, the card ticks over at an acceptable 41dB (noise level tested from 30cm away). At full pelt, however, the card blasts out a very noticeable 64dB.
One thing to note here is when we test noise levels we do so with a normal PC setup (minus a case) that's isolated from external noise by a padded box. Now, inevitably, being shut in a box makes temperatures rise quickly so for our test procedure we leave the box open, until the card has reached a steady operating temperature, then quickly close it and take a noise measurement.
This normally leaves us a decent window of time (a minute or so) before temperatures and thus fan speed start to ramp up significantly. However, with this card although the fan speed was lower before enclosing it, it ramped up so quickly (within a matter of seconds) that we felt this was a fair indicator of expected noise levels. If you do have a particularly well ventilated case it might run a bit quieter, but considering the extra ventilation you'll need the overall noise of your PC will probably still be significant.
Another thing to consider with regards installing this card is its power requirements. It requires both a six-pin and an eight-pin PCI-E auxiliary power connection, the connectors for which run along the top edge. Most decent modern power supplies rated to above 400W should have these connections, but it's worth double checking yours before you buy.
If money really is no object for you then you can run two or even three of these cards together in an SLI configuration for the ultimate in performance. The connectors for doing so are incorporated into the top edge of the PCB as per usual. You don't, however, get any connector ribbons in the box: these should be provided with compatible motherboards.
What you do get in the box is a clear if slightly dated installation manual (seriously, windows XP screenshots?!), a driver CD, and some Nvidia tech demos that show off various DirectX 11 features and the potential of CUDA (Nvidia's general-computing-on-a-graphics-card platform), which is used to accelerate many tasks like video playback and pdf reading. Also present are two power cables, one for converting two Molex connectors to a six-pin PCI-E connector, and one for converting two six-pin PCI-E connectors to one eight-pin connector. Finishing things off are adapters for DVI-to-VGA and mini-HDMI-to-HDMI.