October 10, 2026Cardiology in Review
The Impact of Renin–Angiotensin System Inhibitors on Postoperative Outcomes Following Coronary Artery Bypass Grafting
Key result
Early post-CABG RAS inhibitor use is linked to fewer major adverse cardiovascular events.
- n=47,821
Why the study?
The role of renin-angiotensin system inhibitors initiated within 30 days after CABG on postoperative outcomes is not clearly defined.
Does initiation of renin-angiotensin system inhibitors within 30 days after CABG improve postoperative outcomes in patients undergoing coronary artery bypass grafting?
Key Points
- To evaluate the effect of renin–angiotensin system inhibitors initiated within 30 days after coronary artery bypass grafting on postoperative cardiovascular outcomes and mortality.
- Systematic search of PubMed, Web of Science, Scopus, and the Cochrane Library through May 2025.
- Included 5 studies (3 randomized controlled trials and 2 retrospective cohorts) encompassing 47,821 patients (28,917 receiving inhibitors and 18,904 controls).
- Inhibitor therapy initiated within 30 days post-surgery was generally associated with a lower rate of major adverse cardiovascular events, showing the greatest reductions in patients with heart failure.
- All-cause mortality outcomes were mixed across studies, with 2 studies demonstrating reduced mortality risk and 2 reporting no significant difference.
- Cardiovascular mortality findings varied, showing a marked reduction in 1 study, a transient early increase in 1 study, and no significant change in another.
Study Design
Type
Systematic Review (n=47,821)
Structured PICO
Does initiation of renin-angiotensin system inhibitors within 30 days after CABG improve postoperative outcomes in patients undergoing coronary artery bypass grafting?
P
Population
47,821 patients across 5 studies (3 RCTs, 2 cohorts) undergoing coronary artery bypass grafting, evaluating the initiation of renin-angiotensin system inhibitors within 30 days postoperatively.
I
Intervention
Renin-angiotensin system inhibitors (RASi), comprising ACE inhibitors and ARBs, initiated within 30 days after CABG, alone or with other cardiovascular medications.
C
Comparator
Patients who did not receive RASi after CABG.
O
Outcome
Postoperative outcomes including major adverse cardiovascular events (MACE) and all-cause mortality.composite
Initiating RASi within 30 days post-CABG may reduce major adverse cardiovascular events, particularly in patients with heart failure, but its impact on all-cause and cardiovascular mortality remains variable.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The initiation of ACE inhibitor therapy within 7 days of coronary artery bypass graft surgery does not improve clinical outcomes in low-risk patients without a conventional indication for it”
MEMichel E. BertrandProfessor of cardiology, University of Lille
“It may be that the substantial quinapril dose led to an increase in the release of bradykinin, further promoting inflammation in a postsurgical population that had an ongoing highly active inflammatory process, with a resultant increase in ischemic events.”
Implication
Supports early post-CABG RASi use to reduce MACE, especially in HF; leaves mortality effects unresolved and requires dedicated RCTs.
Abstract
Patients undergoing coronary artery bypass grafting (CABG) remain at high risk of major adverse cardiovascular events and death despite successful revascularization, and the role of renin-angiotensin system inhibitors (RASi), comprising angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, in this setting is not clearly defined. We systematically reviewed the effect of RASi initiated within 30 days after CABG on postoperative outcomes. PubMed, Web of Science, Scopus, and the Cochrane Library were searched through May 2025 for randomized controlled trials and observational studies comparing patients who received RASi after CABG, alone or with other cardiovascular medications, with those who did not. Five studies (3 RCTs and 2 retrospective cohorts) comprising 47,821 patients (28,917 RASi recipients and 18,904 controls) were included. RASi use after CABG was generally associated with a lower rate of major adverse cardiovascular events, with the largest reductions observed in patients with heart failure. The effect on all-cause mortality was inconsistent: 2 studies reported a reduced risk, whereas 2 reported no significant difference. Cardiovascular mortality findings were similarly variable, with 1 study showing a marked reduction, 1 an early increase in the composite endpoint that attenuated over longer follow-up, and 1 no significant change.
Discussion
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Cite This Study
Mansour et al. (2026) conducted a systematic review in Coronary artery bypass grafting (CABG) (n=47,821). Renin-angiotensin system inhibitors (RASi) vs. No renin-angiotensin system inhibitors after CABG was evaluated on Postoperative outcomes including major adverse cardiovascular events and mortality. Renin-angiotensin system inhibitors initiated within 30 days after CABG were associated with lower rates of major adverse cardiovascular events, although the effect on mortality was inconsistent.