<International Circulation>:  If you are talking about where these patients are deriving their risk from， the first thing you would say to treat are these traditional risk factors: glycemic control， blood pressure and LDL-C. Is that correct?

　　Prof. Wong: We certainly know that you get the biggest bang for your buck in controlling， for example， LDL-C as well as blood pressure. Recent trials in people with diabetes have not really shown a conclusive benefit with respect to aggressively managing A1C levels to reduce cardiovascular risk. We get a lot of benefit from both lipid and blood pressure control， however the problem is， because people with diabetes frequently have a mixed dyslipidemia and the HDL and triglycerides in particular are not adequately addressed while often the individual will be at recommended LDL-C levels.

　　<International Circulation>: If you were talking to clinicians about their priorities you would be saying to get LDL down to recommended levels first and then start thinking about the triglycerides and HDL?

　　Prof. Wong: The current guidelines in people with diabetes are to give statins to aggressively manage the LDL as well as other vascular risk issues such as inflammation which， as well as other pleiotropic effects， the statins have. So they are the first recommended therapy. Certainly blood pressure control is also very important and we are not doing a good enough job with that. As far as management of HDL and triglycerides， what is interesting is that recent trials， particularly the ACCORD-Lipid trial， which took a very diverse group of people with diabetes， overall did not show any added benefit of adding a fibrate， namely fenofibrate， on top of a statin in so far as further reducing cardiovascular risk. However， what is often underappreciated is that the subgroup of people in that study as well as other clinical trials that have involved people with diabetes， who have both low HDL and high triglycerides actually have been seen to benefit from added fibrate therapy. I think that is something that we let slip under the rug as the subgroup analysis was not the primary focus of these trials. It is something that I think is extremely important not to forget and in people who do have both low HDL and high triglycerides， I do believe there is an important role for fibrate and/or niacin therapy to help adequately address this residual risk. 

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