In a 149-patient trial evaluating the use of quinapril after surgery, investigators noted a reduc- tion in the composite outcome of angina, death, MI, repeat revascularization, stroke, or transient ischemic attacks in patients who received quinapril for 1 year compared with pla- cebo (3.5% versus 15%, quinapril versus placebo; P=0.02).232 However, these findings were not confirmed in the larger, mul- ticenter Ischemia Management With Accupril Post-Bypass Graft via Inhibition of the Converting Enzyme (IMAGINE) trial of 2253 stable CABG patients. In this study, patients were excluded from randomization if they already had indications for ACE inhibitor therapy such as LV dysfunction, insulin- dependent diabetes mellitus, or renal dysfunction. Quinapril (40 mg daily) had no benefit compared with placebo when initiated within 7 days after surgery, with a 13.7% incidence of the primary composite end point (cardiovascular death, car- diac arrest, nonfatal MI, unstable angina or heart failure requir- ing hospitalization, and stroke) among quinapril patients and 12.2% in the placebo group (HR, 1.15; 95% CI, 0.92 1.42; P=0.21) 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 (P=0.04), and adverse events (such as hypotension) were also increased in the quinapril group, particularly during the first 3 postop- Thus, in this select trial population, routine ACE inhibitor therapy led to more harm than benefit when initiated early after CABG. In those patients who remain above the BP goal despite a suitably titrated regimen including a -blocker and, if appro- priate, an ACE inhibitor, then a calcium channel blocker or a diuretic can be considered as a next therapy choice.A long-act- ing dihydropyridine calcium channel blocker can effectively reduce BP and prevent graft spasm (radial artery conduit) and may offer an antianginal effect. 