Objective-Human treatment with ezetimibe results in a moderate 50% to 54% decrease in cholesterol absorption and a 15% to 20% decrease in plasma LDL-cholesterol levels; nevertheless, the efficacy of ezetimibe therapy has been recently challenged by the ENHANCE trial. We examined the efficacy of a moderate decrease in cholesterol absorption in preventing atherosclerosis formation in the mouse. Methods and Results-Congenic 14DKK animals, consisting of a castaneus (CASA/Rk) chromosome 14 interval introgressed onto the C57BL/6J background, displayed a moderate decrease in cholesterol absorption rates. The effect of moderately decreased absorption on atherosclerosis formation was determined in 14DKK apolipoprotein E knockouts (14DKK-apoEKO). When compared to chow diet-fed control apoEKO mice, congenic 14DKK-apoEKO displayed a moderate 41% decrease in cholesterol absorption rates, 30% to 37% decrease in plasma cholesterol levels, and a 70% decrease in atherosclerosis formation. Studies on cholesterol efflux and reverse cholesterol transport (RCT) from 14DKK bone marrow-derived macrophages rejected a 14DKK intervaldependent atheroprotective effects that operate in macrophages. In contrast, 14DKK-apoEKO congenics were characterized by a 60% increase in RCT from peripheral tissue macrophages. Conclusions-These studies strongly suggest that moderately decreased cholesterol absorption rates result in a large atheroprotective effect attributable to a decrease in plasma cholesterol levels and an increase in RCT from peripheral tissue macrophages. Key Words: cholesterol Ⅲ absorption Ⅲ atherosclerosis Ⅲ reverse cholesterol transport Ⅲ macrophage T he absorption of cholesterol from the intestine is an important determinant of plasma cholesterol levels, a well-established risk factor for atherosclerotic cardiovascular diseases. Clinical studies that examined the effect of a specific and potent cholesterol absorption inhibitor, ezetimibe, on cholesterol absorption and plasma cholesterol levels reported a proportional reduction of 50% to 54% in absorption rates, from 50% to 23%, and a decrease of 15% to 20% in plasma low-density lipoprotein cholesterol (LDL-cholesterol) levels. 1,2 Previous cholesterol-lowering trials indicated that every 1% decrease in plasma LDLcholesterol is expected to decrease the risk for major cardiovascular events by 1%. Based on these estimates treatment with ezetimibe is expected to decrease the risk for cardiovascular events by 15% to 20%, a premise that is currently tested by several ongoing clinical trials. 3,4 Interestingly, and in striking contrast with these expectations, the recently published ENHANCE trial is challenging this view. 5 This trial compared the effect of treatment with simvastatin to combined therapy with simvastatin plus ezetimibe on atherosclerosis formation in heterozygous familial hypercholesterolemic patients. Interestingly, when compared to the simvastatin-treated group, the addition of ezetimibe resulted in further significant decrease in plasma LDL-cholesterol levels; however...