Patient description: A 46-year-old man presents with dizziness and frequent headaches. He has a family history of CAD, but no other cardiovascular risk factors such as smoking, high blood pressure, and diabetes mellitus and is physically active. The patient's LDL-C and HDL-C levels were 545 and 53 mg/dL, respectively. His fasting glucose and triglyceride levels (85 and 158 mg/dL, resp.) were within normal limits. The patient reported no use of lipid-lowering medications. Neck auscultation revealed a systolic murmur 3+/6+ in the neck, radiating to the skull. Ultrasonography of the carotid arteries, revealed severe stenosis in the left internal carotid artery (LICA), as well as moderate stenosis in the right internal carotid artery (RICA) estimated between 40% and 50%. For the LICA, the peak-systolic (PSV) and end-diastolic velocity (EDV) cutoff values were 208.5 cm/s and 54.5 cm/s, respectively; RICA PSV was 91.72 cm/s and RICA EDV was 37.37 cm/s. Plaque was observed in the anterior and posterior walls of the internal carotid artery and common carotid artery, which were characterized as bulky plates extending to the middle third of the internal coronary arteries (ICAs) and as predominantly echogenic and hyperechoic, with less than 50% of the area being echolucent with uneven surfaces.

Clinical trial eligibility criteria: eligible ages (years): 40.0-999.0,  Cardiovascular Disease Hypertension Hyperlipidemia Diabetes Carotid Atherosclerosis American Indian men and women 40 years of age or older 2. Type 2 DM (according to 1997 ADA and/or previously diagnosed by former ADA or WHO criteria): fasting plasma glucose >= 7.0 mmol/L (126 mg/dL) or 2-hour glucose >= 11.0 mmol/L (>200 mg/dL) after a 75-gram oral glucose tolerance test. 3. LDL cholesterol >= 100 mg/dL. within the previous 12 months. 4. Systolic BP >= 130 mm Hg. within the previous 12 months  New York Heart Association Stage III IV congestive heart failure. 2. SBP >180 mmHg (2% of population) or patients with known causes of hypertension. 3. History of angioedema. 4. Any medical condition that study physicians believe would interfere with study participation or evaluation of results. 5. Mental incapacity and/or cognitive impairment on the part of the patient that would preclude adequate understanding of, or cooperation with, the study protocol. 6. Serum hepatic transaminase levels  2X the upper limit of normal. 7. Participation in any clinical trial of any investigational medication within 3 months prior to this trial. 8. Renal insufficiency as indicated by serum creatinine >2.0 for women and >2.4 for men. 9. Diagnosis of primary hyperlipidemia in medical record. 10. Secondary hypercholesterolemia due to hypothyroidism or nephrotic syndrome. Patients on stable doses of thyroid replacement therapy will be eligible. 11. Presence of malignancy or history of any cancer except skin cancer within the past 5 years. 12. Pregnancy or lactation. Premenopausal women will be requested to use birth control methods throughout the study and provided educational materials about the risks of using the study medications during pregnancy. 13. Unable to obtain quantifiable carotid measure during screening examination. 14. Concomitant long term use of cyclosporins (Sandimmune), macrolide antibiotics (erythromycin -many generic and brand name forms, clarithromycin, Biaxin, and Zithromax), azole antifungals (itraconazole-Sporanox, ritonavir, Norvir, and nelfinavir (Viracept). 15. Orthostatic hypotension as defined by the following: 1. The individual has a measured fall of >20 mmHg in systolic BP upon standing associated with symptoms lasting more than one minute (or severe symptoms that would not allow further lowering of BP) 2. The standing systolic blood pressure is less than 90 mm. 16. Triglyceride level >350 mg/dl. 17. Severe aortic stenosis with valve area <=1.0 square cm