Effects of angiotensin-converting enzyme inhibition in low-risk patients early after coronary artery bypass surgery.
BACKGROUND
Early after coronary artery bypass surgery (CABG), activation of numerous neurohumoral and endogenous vasodilator systems occurs that could be influenced favorably by angiotensin-converting enzyme inhibitors.


RESULTS
The Ischemia Management with Accupril post-bypass Graft via Inhibition of the coNverting Enzyme (IMAGINE) trial tested whether early initiation (< or = 7 days) of an angiotensin-converting enzyme inhibitor after CABG reduced cardiovascular events in stable patients with left ventricular ejection fraction > or = 40%. The trial was a double-blind, placebo-controlled study of 2553 patients randomly assigned to quinapril, target dose 40 mg/d, or placebo, who were followed up to a maximum of 43 months. The mean (SD) age was 61 (10) years. The incidence of the primary composite end point (cardiovascular death, resuscitated cardiac arrest, nonfatal myocardial infarction, coronary revascularization, unstable angina or heart failure requiring hospitalization, documented angina, and stroke) was 13.7% in the quinapril group and 12.2% in the placebo group (hazard ratio 1.15, 95% confidence interval 0.92 to 1.42, P=0.212) over a median follow-up of 2.95 years. The incidence of the primary composite end point increased significantly in the first 3 months after CABG in the quinapril group (hazard ratio 1.52, 95% confidence interval 1.03 to 2.26, P=0.0356). Adverse events also increased in the quinapril group, particularly during the first 3 months after CABG.


CONCLUSIONS
In patients at low risk of cardiovascular events after CABG, routine early initiation of angiotensin-converting enzyme inhibitor therapy does not appear to improve clinical outcome up to 3 years after CABG; however, it increases the incidence of adverse events, particularly early after CABG. Thus, early after CABG, initiation of angiotensin-converting enzyme inhibitor therapy should be individualized and continually reassessed over time according to risk.
Rouleau
Jean L
JL
Research Center, Montreal Heart Institute, 5000 Belanger St East, Montreal, Quebec, H1T 1C8, Canada. jean.rouleau@umontreal.ca
Warnica
Wayne J
WJ
Baillot
Richard
R
Block
Pierre J
PJ
Chocron
Sidney
S
Johnstone
David
D
Myers
Martin G
MG
Calciu
Cristina-Dana
CD
Dalle-Ave
Sonia
S
Martineau
Pierre
P
Mormont
Christine
C
van Gilst
Wiek H
WH
D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage / Q000009:adverse effects / Q000494:pharmacology*; D002318:Cardiovascular Diseases / Q000517:prevention & control; D001026:Coronary Artery Bypass / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010919:Placebos; D000077583:Quinapril; D044005:Tetrahydroisoquinolines / Q000008:administration & dosage* / Q000009:adverse effects / Q000494:pharmacology; D017211:Treatment Failure; D016896:Treatment Outcome; D014664:Vasodilation / Q000187:drug effects; D016277:Ventricular Function, Left
D000806:Angiotensin-Converting Enzyme Inhibitors; D010919:Placebos; D044005:Tetrahydroisoquinolines; D000077583:Quinapril