Metabolic Syndrome in Middle Eastern Patients with Atherosclerotic Cardiovascular Disease: A High Burden Driven by Cumulative Risk Factors

Background: Metabolic syndrome (MS), characterized by a constellation of interrelated cardiometabolic abnormalities, markedly amplifies cardiovascular risk. Despite the high prevalence of atherosclerotic cardiovascular disease (ASCVD) in the Middle East, evidence regarding the burden and determinants of MS in this high-risk population remains limited. This study aimed to estimate the prevalence of MS and identify its independent predictors among Middle Eastern patients with established ASCVD. Methods: This comprehensive analysis integrated data from two complementary sources: a prospective cohort derived from the Jordan SMuRF-less Study, which enrolled adults (≥18 years) with confirmed ASCVD across nine centers in Jordan, and a pooled retrospective dataset from six regional cardiovascular registries. Standardized case report forms were used to collect demographic, clinical, and laboratory data. Participants were stratified according to the number of standard modifiable risk factors (SMuRFs) into three categories (0, 1–2, and 3–4 SMuRFs). Multivariable logistic regression analysis was conducted to determine independent predictors of MS. Results: Among 1016 patients with ASCVD, MS was present in 42.7% of the cohort. The prevalence of MS demonstrated a significant graded increase with higher SMuRF burden, rising from 2.2% in patients without SMuRFs to 28.3% in those with one to two SMuRFs and 62.2% in those with three to four SMuRFs (p < 0.001). Patients with MS were significantly older and exhibited higher body mass index and triglyceride levels, lower high-density lipoprotein cholesterol, and a greater prevalence of hypertension, diabetes mellitus, dyslipidemia, chronic kidney disease, and heart failure (all p < 0.001). Independent predictors of MS included advanced age, diabetes mellitus, hypertension, chronic kidney disease, heart failure, elevated body mass index, and increased triglyceride levels. In contrast, higher HDL cholesterol and smoking were inversely associated with MS. Conclusions: MS is highly prevalent among Middle Eastern patients with ASCVD and is strongly associated with cumulative SMuRF burden in a graded manner. These findings highlight the urgent need for targeted, region-specific strategies focusing on early identification and comprehensive management of cardiometabolic risk in this vulnerable population.