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Background: Our aim was to explore clinical outcomes between patients with- and without of optimal medical therapy (OMT) in patients with reduced left ventricular ejection fraction (LVEF) undergoing coronary artery bypass graft surgery (CABG).

Methods: In this single-centre observational study, all patients who underwent isolated CABG with a preoperative LVEF of ≤ 40% between 2012 and 2021 were included. Individual data were collected from the medical health records and the register Carath. OMT was defined as prescription of renin-angiotensin-aldosterone system inhibitor (RAAS-I), beta-blocker (BB), Acetylsalicylic acid (ASA) and statins.

Results: 102 patients were identified. The frequency of patients with OMT was 44% at admission and 67% 72%, 69% and 68% at discharge, 2 months, 1 year and 2 years follow-up. Patients with OMT at discharge had a significant longer median time to the composite endpoint of first-time hospitalization and all-cause mortality compared to the No-OMT group (1.7 versus 7.1 years, log rank p = 0.0038). OMT at discharge was associated with a lower adjusted risk of all-cause mortality and first-time hospitalization for heart failure (adjusted hazard ratio, 0.25; 95% confidence interval, 0.11–0.58; p = < 0.001).

Conclusions: The prescription rate of OMT increased until the 2 months follow-up with no further increases in dose at 1 year and 2 years follow-up. Patients undergoing CABG with a preoperative reduced left ventricular ejection fraction that were prescribed OMT at discharge had better outcomes in terms of a reduced risk of hospitalization for heart failure and all-cause mortality.