Ischemia management with accupril post bypass graft via inhibition of angiotensin coNverting enzyme (IMAGINE): A multicentre randomized trial - design and rationale

BACKGROUND: Coronary artery bypass grafting (CABG) remains the revascularization treatment of choice for patients with severely symptomatic or life-threatening coronary artery disease (CAD). However, 9% to 25% of the patients undergoing CABG will suffer a recurrent ischemic event such as death, recurrent infarction, angina or repeat revascularization. The pathophysiological processes particular to the CABG procedure that may affect graft endothelial function are most active in the early phase after surgery. Angiotensin-converting enzyme (ACE) inhibition has been shown to be effective in reducing or preventing ischemic events in patients with and without left ventricular dysfunction, and in those at high risk for CAD. Nonetheless, no large clinical trail has investigated this role of ACE inhibition in preventing ischemic events early after CABG. OBJECTIVE: The Ischemia Management with Accupril post bypass Graft via Inhibition of angiotensin converting Enzyme (IMAGINE) study addressed whether ACE inhibition initiated early after CABG improves short and long term outcomes in patients after CABG. PATIENTS AND METHODS: This multicentre, multinational trial recruited 2204 patients with an uncomplicated course early after CABG from 55 to 65 medical care facilities in Canada, The Netherlands, Belgium and France. Eligible patients with normal left ventricular function were randomly assigned to placebo or quinapril (titrated up to 40 mg daily where possible) within seven to 10 days after CABG. All patients were followed up closely for a minimum of 12 months after random placement. The median treatment period is expected to be approximately 27 months