In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study of patients with type 2 diabetes mellitus, adding fenofibrate to simvastatin did not reduce fatal cardiovascular events, nonfatal MI, or nonfatal stroke compared with simvastatin alone.177 A meta-analysis of 18 trials found that fibrate therapy produced a 10% (95% CI, 0 18) relative reduc- tion in the risk for major cardiovascular but no benefit on the risk of stroke (RR reduction, 3%; 95% CI, 16 to 9).178 Ezetimibe lowers blood cholesterol by reducing intestinal absorption of cholesterol. In a study of familial hypercholesterol- emia, adding ezetimibe to simvastatin did not affect the progres- sion of carotid IMT more than simvastatin alone.179 In another trial of subjects receiving a statin, niacin led to greater reductions in mean carotid IMT than ezetimibe over 14 months (P=0.003).180 Counterintuitively, patients receiving ezetimibe who had greater reductions in the LDL cholesterol had an increase in the carotid The rate of major cardiovascular events was lower in those randomized to niacin (1% versus 5%; P=0.04). Stroke events were not reported. A clinical outcome trial comparing ezetimibe and simvastatin with simvastatin alone on cardiovascular outcomes is in progress.181 Ezetimibe has not been shown to decrease cardiovascular events or stroke. Dyslipidemia: Recommendations 1. In addition to therapeutic lifestyle changes, treat- ment with an HMG coenzyme-A reductase inhibitor (statin) medication is recommended for the primary prevention of ischemic stroke in patients estimated to have a high 10-year risk for cardiovascular events as recommended in the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults 169 (Class I; Level of Evidence A). 2. 