There was an association between niacin therapy and coronary heart disease event (OR, 0.75; 95% CI, 0.59 0.96) but not with the incidence of stroke (OR, 0.88; However, there are serious safety concerns about niacin therapy. The Heart Protection Study 2 Treatment of HDL to Reduce the Incidence of Vascular Events (HPS2- THRIVE) trial involving 25693 patients at high risk for vascu- lar disease showed that extended-release niacin with laropiprant (a prostaglandin D2 signal blocker) caused a significant 4-fold increase in the risk of myopathy in patients taking simvastatin.174 Fibric acid derivatives such as gemfibrozil, fenofibrate, and bezafibrate lower triglyceride levels and increase HDL cho- lesterol. The Bezafibrate Infarction Prevention study, which included patients with prior MI or stable angina and HDL cho- lesterol 45 mg/dL, found that bezafibrate did not significantly decreaseeithertheriskofMIorsuddendeath(primaryendpoint) or stroke (secondary end point).175 The Veterans Administration HDL Intervention Trial of men with coronary artery disease and low HDL cholesterol found that gemfibrozil reduced the risk of all strokes, primarily ischemic strokes.176 In the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study, fenofibrate neither decreased the composite primary end point of coronary heart disease death or nonfatal MI nor decreased the risk of stroke. 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. 