Objective: The objective of this study was to assess predictive value of various arterial markers for cardiovascular (CV) events in patients with metabolic syndrome (MS).

Design and methods: A follow-up study enrolled 2728 (53.95 ± 6.18 years old, 63% women) MS patients without overt CV disease. Patients were followed-up for 3.9 ± 1.7 years for CV events. Various CV risk factors and arterial markers, such as brachial flow-mediated dilatation (FMD), carotid intima-media thickness (cIMT), carotid stiffness index (CSI), aortic pulse wave velocity (aPWV) and cardio-ankle vascular index (CAVI) were assessed.

Results: Over the follow-up period, 83 (3%) patients had at least one CV event. In a multivariate stepwise Cox proportional hazard regression analysis, an increase in aPWV [HR 1.21 (1.04–1.4), p = 0.016] and cIMT [HR 1.003 (1.001–1.003), p = 0.036] and decrease in FMD [HR 0.30 (0.16–0.56), p < 0.001] was independently associated with the occurrence of the CV event.

In a two-level survival trees analysis we established that patients with cIMT>793 mcm had higher CV risk and their prognosis was further compromised with an FMD <= 0.23 mm, whereas in patients with cIMT <=793 mcm, aPWV but not FMD was of greater predictive value. The lowest Kaplan-Meier cumulative proportion surviving was observed in patients with cIMT>793 mcm and aPWV values above the cut-off point 10.5 m/s (p < 0.001).

Conclusions: In the middle-aged patients with MS and increased cIMT, aPWV was strongest independent CV event predictor, whereas in patients with relatively low cIMT values, CV risk was associated primarily with endothelial dysfunction.