Is HPS2-THRIVE the death knell for niacin?

Niacin is a lipid-modifying therapy with proven efficacy for reducing cardiovascular events as monotherapy and when used in combination with other lipid-modifying medications impacts rates of atherosclerotic disease progression. Large outcome trials using niacin against a background of statin therapy with optimal control of atherogenic lipoprotein burden in serum were unable to demonstrate incremental benefit of niacin beyond statin therapy. We address 2 key questions: (1) Can the results from randomized clinical trials performed in stable ischemic heart disease populations (AIM-HIGH and HPS2-THRIVE) be applied to patients who sustain an acute coronary syndrome or myocardial infarction? (2) Are patients with very low baseline levels of high-density lipoprotein cholesterol (<30 mg/dL) at particularly high risk for subsequent cardiac events?