The prevalence of HF increased with the number of components of the metabolic syndrome. However, when the homeostasis model assessment was included in the multivariate mod- el, the odds ratio of the metabolic syndrome was no longer significant, suggesting that 90.7% of the associa- tion between the metabolic syndrome and HF was at- tributed to insulin resistance. Interestingly, the strength of this association varied among ethnic groups, with the homeostasis model assessment explaining 85.7% of the association in whites, 95.7% in Mexican Americans, and only 32.7% in blacks. The first prospective study to confirm that the meta- bolic syndrome is a significant predictor of incident HF comes from the Uppsala Longitudinal Study of Adult A cohort of 2314 men (age, 50 years) without HF, MI, or valvular disease at baseline was followed up for 20 years. With the application of a modified ver- sion of the ATP III (Adult Treatment Panel III) criteria (BMI was used instead of waist circumference), the risk of incident HF was 5.3 per 1000 person-years for those with the metabolic syndrome versus 1.7 per 1000 person-years for those without the metabolic syn- drome. The metabolic syndrome increased the risk of developing HF >3-fold and remained significant after adjustment for established risk factors for HF. The inci- dence of HF in those with the metabolic syndrome began Bozkurt et al diverging from those without the syndrome at 10 years of follow-up, suggesting that long-term follow-up may be necessary to truly estimate the impact of the metabolic syndrome. The increased risk of HF with the metabolic syn- drome has consistently been demonstrated in other populations. 