OBJECTIVE:In the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study, clinical, metabolic variables as well as office, home, and ambulatory blood pressure (BP) values were measured contemporaneously at baseline and after a ten-year period of follow-up, which allowed us to assess the value of selective and combined elevation of these BPs in predicting new onset metabolic syndrome (MetS). DESIGN AND METHOD:The present analysis included 1,182 participants without MetS at baseline, as defined by the APT III criteria. Based on office, 24-hour ambulatory BP and home values, subjects were divided into 4 groupsnormal, with coat hypertension (WCH), masked hypertension (MH); and sustained hypertension (SH). RESULTS:As compared to subjects with in-office and out-of-office BP normality a greater age- and gender-adjusted incidence of new onset Mets was observed in WCH (OR = 2.03, CI:1,21-3.41, p = 0.007), MH (OR = 2.55, CI:1.26–5.17; p = 0.009) and SH (OR = 2.28, CI:1.43–3.99, p = 0.0009) when out-of-office BP was defined by ambulatory criteria. This was not the same when out-of-office BP was based on home criteria, as only the WCH group showed a significant greater OR risk (2.16, CI1.28–3.63, p = 0.003). CONCLUSIONS:Our study provides evidence that isolated or combined BP elevations when identified by office/ambulatory measurements, carry an increase in risk of new onset MetS, while classifying the population by combining office/home BPs only WCH is associated with a greater risk of incident MetS. In a clinical perspective, a comprehensive evaluation of BP status based on office/ambulatory measurements may substantially improve the risk stratification of new onset MetS and to activate measures for its prevention