These side effects include excessive hypotension, hyperkalemia, and worsening renal function necessitating dis- continuation of therapy.248,249,252 Aldosterone Antagonists Spironolactone is a nonselective aldosterone antagonist that has demonstrated benefits for patients with severe heart fail- ure. In the RandomizedAldactone Evaluation Study (RALES), spironolactone was associated with a 30% RR reduction in overall mortality and a reduction in heart failure hospitaliza- tion and symptoms among patients with NYHA class III to IV symptoms and an EF <35%.253 Subsequently, the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) extended the benefits of aldoste- rone antagonists to patients with mild heart failure (includ- ing NYHA class II symptoms) and an EF <35% with the use It is important to note that an aldosterone receptor antagonist is indicated as an add-on therapy for patients who have persistent heart failure symptoms despite treatment with both classes of neurohormonal inhibitors ( -blockers and ACE inhibitor/ARBs). In accordance with both aforementioned studies253,254 and previous guidelines,236 aldosterone antagonists appear most applicable to post-CABG patients with persistent LV dysfunction (EF <35%) and mild or more severe heart failure symptoms. Careful monitoring of potassium, renal function, and diuretic dosing should be per- formed at initiation and serially thereafter in these patients. Aldosterone antagonists should be avoided in patients with estimated glomerular filtration rate <30 mL min 1 or potassium levels >5.0 mEq/L. Devices A substantial body of evidence supports the use of implantable cardioverter-defibrillators (ICDs) to prevent sudden cardiac Kulik et al Secondary Prevention After CABG 941 death among patients with reduced EF.255 257 However, ICD therapy at the time of surgical revascularization has failed to improve patient outcomes. 