<International Circulation>: What other trials， and I am aware they are post hoc analyses， apart from ACCORD have shown comparable reductions in risk as was demonstrated in ACCORD?

　　Prof. Wong: One important trial was the FIELD trial that also involved fenofibrate and that was in people who had type 2 diabetes. The trial also did not show an overall benefit but there was a risk reduction seen in the subgroup of people with low HDL and elevated triglyceride levels. There were also a few other trials such as the BIP trial involving bezafibrate as well as post hoc analyses from the Helsinki Heart Trial and the HDL Intervention Trial that have shown benefits as well in the subgroup of people specifically with low HDL and high triglycerides.

　　<International Circulation>: What the fibrates were meant to do before these trials were started was to raise HDL and lower triglycerides yet they have picked a population that was all over the board.

　　Prof. Wong: Exactly and that is an extremely important point. The fact is that most of these trials involve people who have a mixture of different types of dyslipidemia. What was happening in these trials was that we were giving fibrate therapy to people who would not necessarily get actual fibrate therapy in clinical practice because they did not have the characteristic low HDL/high triglycerides which is common in people with diabetes however there are many individuals with diabetes who do not have these lipid abnormalities. In these trials， these people were still included and may represent why benefit was not seen in the overall population studies.

　　<International Circulation>: The take-home message here may not be that raising HDL in general lowers your risk but if you have an HDL deficiency or over a certain threshold of triglycerides， then you need to consider HDL and triglycerides. If your levels are normal then you don’t need treatment.

　　Prof. Wong: The epidemiological data will suggest that you are most likely to benefit if you have high triglycerides and low HDL to begin with but if these lipid fractions are normal then it is much less likely you are going to benefit from these therapies. Certainly the fibrate studies tend to support that notion.