A 74-year-old white man with coronary artery disease (CAD) on medical management with isosorbide dinitrate, aspirin, furosemide, and captopril was scheduled for a triple-vessel bypass for the treatment of unstable angina. The patient had a 1% year history of CAD with the following cardiac risk factors: obesity, hypertension, male sex, and age above 70. There was no family history. tobacco use, or diabetes mellitus. The medical history was otherwise significant for congestive heart failure, mild chronic renal failure, and a recent episode of pneumonia with concurrent atrial fibrillation that resolved with the treatment of the infection and digitalization. Physical examination revealed an elderly white man in no acute distress with a blood pressure of 139175 mmHg and a HR of 70 beatsimin, height of 171 cm, and a weight of 86.9 kg. Lungs were clear to auscultation. The heart had a regular rate and no abnormal heart sounds. The patient had 1 + pitting edema of the ankles. No neurologic deficits were noted on a superficial examination, and no bruits were heard over the carotid arteries. Laboratory studies included a hematocrit of 4h.5<6. platelet count of 123,000/1_~L. serum digitalis level of 0.4 ng/mL. serum potassium of 4.4 mEq/L, and serum creatinine of 1.5 mg%. The ECG showed a normal sinus rhythm with lateral ST segment depression and left ventricular hypertrophy. A chest radiograph demonstrated cardiomegaly without evidence of pulmonary edema. The left ventriculogram showed severe hypokinesis in the anterolateral and apical segments and mild hypokinesis of the posterobasal and diaphragmatic segments. Mild mitral regurgitation was noted. Coronary angiography showed that the right coronary artery was dominant and had an 80% proximal stenosis and a 100% distal stenosis, the LAD had a 90% proximal stenosis at the distal left main and origin of the LAD. Finally, a 90% stenosis was seen in the second diagonal artery. Left ventricular ejection fraction determined by MUGA 3 months earlier Was 0.39. The patient was premeditated with morphine, 7 mg. scopolamine, 0.3 mg, IM. and ranitidine. I50 mg. and metoclopramide. 10 mg, PO. Before induction, two peripheral Igh mmHg, pulmonary capillary wedge pressure (PCWP) 8 mmHg, central venous pressure (CVP) I mmHg, and thermodilution cardiac output (CO) 4.3 L!‘min. An intravenous induction was performed with etomidate (18 mg). fentanyl (2 mg). and vecuronium (12 mg). Correct endotra-