Compared to the niacin data (see Recommendation 15), the fibrate data was less robust and lower quality. Patient and provider preferences likely vary because some patients with high TG may be interested in fibrates. However, the Work Group determined the potential for harm outweighed potential benefits given the adverse effects on LFTs, serum creatinine, and the possible increase in CV events in women. Given the lack of benefit in both primary and secondary prevention, the Work Group decided upon a Weak against recommendation. The Work Group had no research recommendations since further research is not likely to change the clinical landscape nor impact this recommendation. Recommendation 17. There is insufficient evidence to recommend for or against using bempedoic acid with or without statins for either primary or secondary prevention. (Neither for nor against | Reviewed, New-added) Discussion Bempedoic acid is a prodrug that is activated by very-long-chain acyl-CoA synthetase-1 to inhibit ATP- citrate lyase and works upstream of hydroxy methylglutaryl coenzyme A. Among patients at risk of CVD who are on statins, intensifying treatment by adding bempedoic acid has not been shown to reduce CVD mortality, all-cause mortality, non-fatal MI, non-fatal stroke, or MACE compared to the placebo group. There were no systematic reviews or meta-analyses that met the inclusion criteria for this CPG s systematic evidence review. Based on an RCT, Ray et al. (2019), treatment with bempedoic acid in addition to statins did not improve outcomes among patients with atherosclerotic CVD, HeFH, or both.[98] However, these findings were imprecise because of low event rates and the short follow-up (12 months), and the study was limited by high attrition. 