{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T11:13:06Z","timestamp":1789038786954,"version":"build-2803163510"},"reference-count":7,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T00:00:00Z","timestamp":1788998400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Cardiovasc. Dev. Dis.","JCDD"],"abstract":"<jats:p>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 \u201cindependent predictors\u201d 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 \u2265140\/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.<\/jats:p>","DOI":"10.3390\/jcdd13090453","type":"journal-article","created":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T10:27:21Z","timestamp":1789036041000},"page":"453","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Comment on Alkouri et al. Metabolic Syndrome in Middle Eastern Patients with Atherosclerotic Cardiovascular Disease: A High Burden Driven by Cumulative Risk Factors. J. Cardiovasc. Dev. Dis. 2026, 13, 240"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7830-6857","authenticated-orcid":false,"given":"Yousef Saleh","family":"Khader","sequence":"first","affiliation":[{"name":"Department of Public Health, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Alkouri, O., Al-Qerem, W., Jarrah, M., Alharbi, G., Alrida, N.A., Alabkal, R.M., Hammoudeh, A.J., Abdelgawad, M.E., Alshehri, A., and Hasan, A.Y. (2026). Metabolic Syndrome in Middle Eastern Patients with Atherosclerotic Cardiovascular Disease: A High Burden Driven by Cumulative Risk Factors. J. Cardiovasc. Dev. Dis., 13.","DOI":"10.3390\/jcdd13060240"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1093\/aje\/kws412","article-title":"The Table 2 Fallacy: Presenting and Interpreting Confounder and Modifier Coefficients","volume":"177","author":"Westreich","year":"2013","journal-title":"Am. J. Epidemiol."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"(2001). Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA, 285, 2486\u20132497.","DOI":"10.1001\/jama.285.19.2486"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1059","DOI":"10.1016\/S0140-6736(05)67402-8","article-title":"The Metabolic Syndrome\u2014A New Worldwide Definition","volume":"366","author":"Alberti","year":"2005","journal-title":"Lancet"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1640","DOI":"10.1161\/CIRCULATIONAHA.109.192644","article-title":"Harmonizing the Metabolic Syndrome: A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity","volume":"120","author":"Alberti","year":"2009","journal-title":"Circulation"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1453","DOI":"10.1016\/S0140-6736(07)61602-X","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies","volume":"370","author":"Altman","year":"2007","journal-title":"Lancet"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"486","DOI":"10.5812\/ijem.3505","article-title":"Normality Tests for Statistical Analysis: A Guide for Non-Statisticians","volume":"10","author":"Ghasemi","year":"2012","journal-title":"Int. J. Endocrinol. Metab."}],"container-title":["Journal of Cardiovascular Development and Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/9\/453\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T10:55:18Z","timestamp":1789037718000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/9\/453"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,10]]},"references-count":7,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["jcdd13090453"],"URL":"https:\/\/doi.org\/10.3390\/jcdd13090453","relation":{},"ISSN":["2308-3425"],"issn-type":[{"value":"2308-3425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,10]]}}}