Hassan et al296 reported a lower mortality in patients with HF with compared with those without the metabolic syndrome (43.8% versus 57.6%) in a retrospective cohort of patients (n=625) admitted with HF. There was a nonlinear decrease in mortality with an increasing number of metabolic syndrome criteria: 68.2% in those with no criteria to 37.0% in those with all 5 criteria. Conversely, a prospective cohort of 865 out- patients with HFrEF (EF <40%) demonstrated a mortality of 24% in those with the metabolic syndrome compared with 16% in those without at 2.6 years of follow-up.297 The Kaplan-Meier curves were similar for up to 4 years of follow-up for both groups and diverged thereafter with higher mortality in the metabolic syndrome group. As described for obesity, hypertension, and dia- betes mellitus, a similar paradoxical effect may ex- ist with respect to the metabolic syndrome: Although obesity, higher BP, and elevated cholesterol are risk factors for the development of HF and mortality in the general adult population, these factors are associated with improved survival in patients with established HF. The metabolic syndrome is associated with higher all- cause and cardiovascular mortality in the general adult but as suggested by Hassan et al,296 the metabolic syndrome may exert an inverse associa- tion with improved survival in the HF population. Further studies are warranted to confirm and better understand this paradox. Treatment of the Metabolic Syndrome Given that overweight and obesity, physical inactivity, and an atherogenic diet contribute to the development of the metabolic syndrome, the institution of lifestyle modification is first-line therapy. 