New approaches in the intensive management of cardiovascular risk in the metabolic syndrome.

When risk factors such as dyslipidemia and hypertension are inadequately controlled in subjects with the metabolic syndrome by lifestyle interventions, pharmacologic approaches are warranted. Statins are first-line pharmacotherapy for dyslipidemia due to their efficacy for lowering low-density lipoprotein (LDL) cholesterol and may also improve high-density lipoprotein (HDL) cholesterol and triglyceride levels. Fibrates and niacin may be useful in combination with a statin for additionally lowering triglycerides or raising HDL cholesterol. Adequate control of hypertension will usually require two or more drugs; agents that block the renin-angiotensin system are particularly useful in this population, given their demonstrated benefits for reducing the burden of cardiovascular events and end-stage renal disease independent of blood-pressure lowering. A multifaceted approach to risk factor management for the metabolic syndrome will have benefits for prevention of type 2 diabetes and cardiovascular disease.