Rouleau Jean L, Warnica Wayne J, Baillot Richard, Block Pierre J, Chocron Sidney, Johnstone David, Myers Martin G, Calciu Cristina-Dana, Dalle-Ave Sonia, Martineau Pierre, Mormont Christine, van Gilst Wiek H
Research Center, Montreal Heart Institute, 5000 Belanger St East, Montreal, Quebec, H1T 1C8, Canada.
Circulation. 2008 Jan 1;117(1):24-31. doi: 10.1161/CIRCULATIONAHA.106.685073. Epub 2007 Dec 10.
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.
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.
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.
冠状动脉旁路移植术（CABG）后早期，多种神经体液和内源性血管舒张系统被激活，而血管紧张素转换酶抑制剂可能对其产生有益影响。
通过抑制转换酶进行旁路移植术后依那普利缺血管理（IMAGINE）试验，旨在测试CABG后早期（≤7天）使用血管紧张素转换酶抑制剂是否能降低左心室射血分数≥40%的稳定患者的心血管事件。该试验是一项双盲、安慰剂对照研究，纳入2553例患者，随机分配至喹那普利组（目标剂量40mg/d）或安慰剂组，随访最长43个月。平均（标准差）年龄为61（10）岁。在中位随访2.95年期间，喹那普利组主要复合终点（心血管死亡、心脏骤停复苏、非致命性心肌梗死、冠状动脉血运重建、不稳定型心绞痛或需住院治疗的心力衰竭、有记录的心绞痛和中风）的发生率为13.7%，安慰剂组为12.2%（风险比1.15，95%置信区间0.92至1.42，P = 0.212）。喹那普利组在CABG后前3个月主要复合终点的发生率显著增加（风险比1.52，95%置信区间1.03至2.26，P = 0.0356）。喹那普利组不良事件也增加，尤其是在CABG后前3个月。
在CABG后心血管事件低风险患者中，常规早期开始血管紧张素转换酶抑制剂治疗在CABG后3年内似乎并未改善临床结局；然而，它增加了不良事件的发生率，尤其是在CABG后早期。因此，CABG后早期，血管紧张素转换酶抑制剂治疗的开始应个体化，并根据风险随时间持续重新评估。
