Cardiac medical therapy following coronary artery bypass graft surgery.

from a creatine kinase-based enzyme rise to a troponin-based rise. Use of beta-blockers in patients with left ventricular (LV) impairment is also strongly supported by numerous controlled trials, and these patients should certainly receive beta-blockers post-CABG. We agree that use of beta-blockers in patients without prior MI (ST-segment or non–ST-segment elevation) or LV impairment is more debatable. We also believe there is sufficient evidence to warrant the use of ACEI in most patients following CABG. In the Heart Outcomes Prevention Evaluation (HOPE) trial, use of the ACEI ramipril improved outcomes in patients with diabetes or known vascular disease but without LV dysfunction (3); approximately 25% of the participants had previously undergone CABG. The small study evaluating quinapril post-CABG showed no effect of the ACEI on the primary end point of change in exercise endurance or incidence of ischemia on Holter monitor (4); however, fewer patients receiving quinapril experienced ischemic events compared with placebo (3.5% vs. 15%; p 0.02), suggesting benefit to those receiving quinapril. Current research suggests that ACEI act as vascular protective agents, and as such most patients undergoing CABG for coronary disease are likely to benefit and should be prescribed them. We agree that aspirin and statins should be used post-CABG. However, we also believe that ACEI should also be routinely used where possible; use of beta-blockers should also be strongly recommended especially in patients with a history of MI and/or LV impairment.