medRxiv (Medicine)
2026-06-24
DOI: HASH:e5e15e063018267357a7448d38e69a7c
Background and Aims Current diagnostic criteria for metabolic syndrome (MetS) may inadequately capture underlying metabolic heterogeneity and associated cardiovascular risks. We aimed to use expanded cardiometabolic variables to identify new cardiometabolic phenogroups with relevance to prognosis and risk stratification. Methods Latent class analysis (LCA) was applied to a discovery cohort (RESET; n=1,034), using the six conventional MetS measures and eight additional variables. A decision tree model was constructed using the most important variables to enable practical phenogroup classification and facilitate external validation. External validation was conducted in three independent cohorts, PICMAN (n = 120), UK Biobank (n = 344,817), and CHARLS (n = 12,145), analysing for proteomic signatures and cardiovascular outcomes. Results Five latent phenogroups were identified in the discovery cohort: Metabolically Preserved with and without isolated hypertension (each n=244; 23.6%), Lean-Insulin Resistant (IR) (n=140; 13.5%), Obese-Insulin Sensitive (IS) (n=211; 20.4%), and Obese-IR (n=195; 18.9%). Lean-IR and Obese-IS showed discordant adiposity and insulin/glycemic status, and a low prevalence of MetS (21.4% and 31.3%, respectively), whereas MetS was high (75.9%) only in the Obese-IR group. A decision tree model using four binary indicators (visceral adiposity, IR, elevated SBP, and HbA1c) accurately classified individuals into the five latent phenogroups and was subsequently deployed for external validation. Validation in PICMAN showed significantly higher liver fat (Mean 9.0% [SD 6.3%]) in Lean-IR versus Metabolically Preserved (Mean 2.8% [SD 1.8%], P=0.002). Plasma proteomic analyses further reflected unique metabolic-inflammation signatures across the 5 groups. Validation in the UK Biobank showed significant association between the latent phenogroups with outcomes of myocardial infarction and stroke. Hazard ratios for the composite outcome after adjusting for age and sex were 1.52 (95% CI, 1.43-1.61) for isolated hypertension, 1.86 (1.75-1.98) for Lean-IR, 1.85 (1.75-1.97) for Obese-IS, and 2.75 (2.56-2.95) for Obese-IR, compared with the Metabolically Preserved group. Conclusion Expanded cardiometabolic risk factors reveal metabolic heterogeneity obscured by current MetS criteria. Incorporating visceral adiposity and IR into a novel classification system refines cardiovascular risk stratification for the management of cardiometabolic disease.