All coronary artery bypass graft surgery patients will benefit from angiotensin-converting enzyme inhibitors.

Angiotensin-converting enzyme (ACE) inhibitors have been shown to prolong survival and to decrease infarct size in patients after acute coronary syndromes.1–3 Evidence now exists that ACE inhibitors are effective in decreasing myocardial injury during coronary artery bypass graft surgery (CABG) and can reduce the incidence of ischemic events in the years after surgery.4,5 It has been suggested that all CABG patients be started on ACE inhibitors, in addition to a statin, aspirin, and -blocker, as part of a cardioprotective strategy to reduce recurrent ischemic events in these patients.6 In this issue of Circulation, Rouleau and coworkers7 present data from the Ischemia Management with Accupril post-bypass Graft via Inhibition of the coNverting Enzyme (IMAGINE) trial that question this benefit for all CABG patients. They conclude that in low-risk CABG patients, routine early initiation of ACE inhibitor therapy does not appear to improve clinical outcomes up to 3 years after surgery and may actually increase adverse events in the early postoperative period. They feel that ACE inhibitor therapy should be individualized and reassessed over time. Are the results of this study applicable to the vast majority of CABG patients? Can we accurately identify patients who are at low risk of developing future cardiovascular events at the time of CABG surgery? What is the best method of initiating ACE inhibitor therapy in the post-CABG patient, and were these guidelines followed by the IMAGINE investigators? Here, I will attempt to answer these questions as we try to determine the role of ACE inhibitor therapy in the CABG patient.