We thank Ribera Casado and Martín Sánchez for their thoughtful reflections on our article,1 and take this opportunity to respond with some comments of our own.
Obtaining a representative sample is always a challenge. However, as we state in the limitations section of our article, we believe that our registry meets the protocol requirements and accurately reflects the patient profile and quality of care at Spanish centers in which cardiologists are responsible for the care of heart failure patients. As Ribera Casado and Martín Sánchez point out, this is clearly evident from the baseline patient characteristics presented in our study: the average age in our registry was lower than in the total population of heart disease patients in Spain, and our population also had a higher frequency of low ejection fraction.
Without contradicting this observation, we should nonetheless point out that Ribera Casado and Martín Sánchez's commentary misinterprets the age data in our registry. They state that no patients in our registry were aged above 73 years. However, this is the third quartile value, not the maximum age (the baseline age data show median and first and third quartiles). So in fact 25% of the patients in the registry were older than 73 years. The age profile of our sample (65 [56-73])1 is similar to that of the full ESC Heart Failure Long-Term Registry (66 [61-79]).2
Moreover, our study focused on whether treatment guidelines were followed for patients with heart failure and low ejection fraction, because the treatments recommended for this group have been demonstrated to improve survival and quality of life. Achieving the recommended dose is difficult even when there is good adherence to treatment guidelines, as there was in our registry. It is therefore understandable if cardiologists dedicate attention to this type of patient during consultations, and this, as we have indicated, is also reflected in the profile of the patients in our study.
We agree with Ribera Casado and Martín Sánchez that many people with heart disease are treated by other specialists, and that these patients have a different profile from those treated by cardiologists; for example, patients treated by other specialists tend to be older, and this population has a higher frequency of preserved ejection fraction and more comorbidity, among other differences. Although this question falls outside the scope of our study, we support the treatment of heart disease patients by a variety of professionals from different specialties and branches of the health sciences.
We thank Servier España for providing unconditional sponsorship for the development of the ESC Heart Failure Long-Term Registry in Spain, through an agreement with the Heart Failure and Heart Transplantation Section of the Spanish Society of Cardiology.