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Purpose: To evaluate the influence of carotid atherosclerosis and metabolic syndrome (MetS) on the prediction of cardiovascular events during a 20-years follow-up.Methods: We studied a population of 529 asymptomatic patients, divided into 2 groups according to the results of the carotid ultrasound evaluation: one without atherosclerotic lesions (198 patients) and a second one with an increased carotid IMT or asymptomatic carotid plaque (331 patients). In each of these groups, we identified two subgroups of subjects with and without MetS. Cardiovascular endpoints were investigated in a 20-years follow-up: acute myocardial infarction, angina, transient ischemic attack, ischemic stroke, abdominal aortic aneurysm, thromboendarterectomy and cardiovascular death.Results: During the follow-up there were 242 cardiovascular events, 144 among patients with MetS (251 patients) and 98 among healthy controls (178 patients) (57.4% vs. 35.2%; P<0.0001). Moreover 63 events occurred in patients with normal carotid arteries while 179 events occurred in patients with subclinical atherosclerosis (31.8% vs. 54.1%; P<0.0001). Among 144 total events occurred in patients with MetS, 36 happened in the subgroup of 80 patients with normal carotid arteries and 108 happened in the subgroup of 171 patients with subclinical atherosclerosis (45% vs. 63.15%; P=0.01). Among 98 total events occurred in patients without MetS, 27 developed in the subgroup of 118 patients with normal carotid arteries and 71 occurred in the subgroup of 160 patients with subclinical atherosclerosis (22.9% vs. 44.4%; P=0.0003). In addition among 63 total events occurred in patients without atherosclerotic lesions, 36 events happened in the subgroup of 80 patients with MetS and 27 events occurred in the subgroup of 118 patients without MetS (45% vs. 22.9%; P=0.0018). Finally, among 179 total events recorded in patients with atherosclerotic lesions 108 events happened in the subgroup of 171 patients with MetS and 71 events happened in the subgroup of 160 patients without MetS (63.15% vs. 44.4%; P=0.0009). The Kaplan-Meier function showed an improved survival in patients without atherosclerotic lesions compared with patients with carotid ultrasound alterations (P=0.0159, HR: 0.7366, CI: 0.5479 to 0.9904).Conclusions: Subclinical atherosclerosis lead to an increased risk of cardiovascular events, especially if it is associated with MetS. Therefore we suggest to investigate the presence of subclinical atherosclerosis in all patients with more than 45 years with cardiovascular risk factors for a better stratification of the global cardiovascular risk.

Subclinical atherosclerosis: independent predictor of cardiovascular events in a 20-years follow up of patients with or without metabolic syndrome