Angiography 4 years after study initiation demonstrated that aggressive cholesterol reduction lowered the incidence of new vein graft occlusions (10% versus 21%, aggressive reduction versus moderate reduction; P<0.0001) and the number of grafts with progression of atherosclerosis (27% versus 39%, aggressive reduction versus moderate reduction; P<0.001).68 In a follow-up study of trial participants 3 years later, the aggressive treatment approach was associated with a 30% reduction in the need for repeat revascularization and a 24% reduction in adverse cardiovascular events (both P=0.001).87 Overall, the Post-CABG trial noted that aggressive lowering of LDL to <100 mg/dL reduced both cardiovascular events and the progression of atherosclerosis in native coronary arter- ies and saphenous vein grafts.68,87 The importance of postoperative LDL reduction with statins has been confirmed in several other randomized and observational studies in the cardiac surgery literature. A small, controlled trial published in 1999 noted that statin treatment started 4 weeks preoperatively and continued for 1 year after CABG reduced the risk of MI both in the perioperative period (0% versus 14%, preoperative statin versus regular care; and during the first year after CABG (0% ver- sus 19%, preoperative statin versus regular care; P=0.03).89 In a cohort study of 7503 patients, statin treatment within 1 month of CABG was independently associated with a reduc- tion in the risk of all-cause mortality (adjusted HR, 0.82; 95% CI, 0.72 0.94; P=0.004) and major adverse cardiovascular Nearly identical findings were reported in 2 observational studies that followed, with significant associa- tions demonstrated between postoperative statin therapy and lower all-cause mortality and cardiac events long term after Of interest, the survival benefits associated with statins after CABG appear to be similar in magnitude to that associated with the use of 2 internal mammary artery grafts compared with the use of only 1 graft.92 In addition to their lipid-lowering effects, statins appear have important non lipid-related actions that may contribute to their beneficial effect.93,94 These cholesterol-independent or pleiotropic properties include improvements in endothelial function, nitric oxide levels, and antioxidant activity, as well as the inhibition of inflammatory responses, vasoconstric- tion, thrombosis, and platelet aggregation.94 98 Administering statins before surgery has been shown to diminish the systemic inflammatory response associated with the use of cardiopul- monary bypass during CABG.99 102 Through antisympathetic activity and the stabilization of ion channels,103 both random- ized and observational studies have illustrated that statin treat- ment significantly reduces the risk of AF after CABG both in the perioperative period and long term after surgery.104 110 Although selection bias cannot be excluded, several nonran- domized, retrospective studies have noted significant asso- ciations between perioperative statin use and a lower risk of postoperative renal dysfunction,111,112 even among patients without elevated lipid profiles before surgery.119 Some investigators have sug- gested that preoperative statin treatment may reduce the risk of mortality late after surgery,117,120 122 but it is also possible that preoperative statin administration simply predicts those who will receive statins after surgery,123 ultimately leading to improved long-term outcomes.78 Recently, attention in the cardiology community has turned toward the use of high-intensity statin therapy to achieve an LDL reduction to 70 mg/dL to further improve cardiovas- cular outcomes in patients with CAD.77,82,124 In the Treating to New Targets (TNT) Trial, 10001 patients with CAD were ran- domized to receive either atorvastatin 80 mg/d or atorvastatin In a subgroup analysis that focused on the 4654 patients with a history of previous CABG, atorvastatin 80 mg was associated with a significantly lower risk for adverse car- and a lower need for repeat revascularization (HR, 0.70; 95% CI, 0.60 0.82; P<0.0001) during follow-up compared with Similar findings, albeit nonsignificant, were also reported in the comparison of intensive statin therapy with standard statin therapy among patients with a history of previous CABG in the Pravastatin or Atorvastatin Evaluation and Infection Therapy Thrombolysis in Myocardial Infarction (PROVE-IT TIMI 22) and the Aggrastat to Zocor (A to Z) tri- Although a potential benefit with high-intensity statin therapy was suggested, these subgroup analyses were limited by the lack of graft patency data and the lengthy time span between surgery and study recruitment. 