Comment on Alkouri et al. Metabolic Syndrome in Middle Eastern Patients with Atherosclerotic Cardiovascular Disease:...

I read with interest the recent study by Alkouri et al. reporting a high prevalence of metabolic syndrome (MS) among Middle Eastern patients with atherosclerotic cardiovascular disease (ASCVD) and a graded increase in MS prevalence with the cumulative burden of standard modifiable risk factors (SMuRFs). The clinical question is important and the assembled cohort is sizeable. However, several methodological features warrant consideration when interpreting the conclusions and, in my view, merit comment. First, the exposure (SMuRF count), the regression predictors, and the outcome (MS) share constituent components, most directly hypertension and the lipid abnormalities, so that the central graded relationship and the interpretation of several "independent predictors" are partly influenced by definitional overlap. Second, the operational MS definition was modified because of limitations in data availability (fasting glucose omitted, body mass index substituted for waist circumference, and a hypertension threshold of ≥140/90 mmHg), which limits direct comparability of the reported 42.7% prevalence with studies using standard definitions. Third, the pooling of one prospective cohort with six heterogeneous retrospective registries, together with an unexplained reduction from a stated 5540 participants to 1016 analyzed, may introduce selection concerns and limits the extent to which the findings are regionally representative of the Middle East. Fourth, several aspects of the statistical reporting would benefit from clarification. I outline these issues and suggest analyses that would strengthen interpretation.