LAUSR

We would like to thank Braber et al. [1] for this opportunity to discuss the results of our study regarding the follow-up of elderly patients with multivessel disease after revascularisation. As stated in the discussion section of our article, we were aware that the design of the study is inherent to risk of bias when comparing two strategies. However, we chose an observational study design on purpose to describe the long-term follow-up in an unselected population. Even though a randomised controlled trial (RCT) may be the best method to approach the most genuine answer regarding the best revascularisation strategy in elderly with multivessel disease, this would require equipoise from the Heart Team’s perspective between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), which is rarely the case, especially in this elderly population. Also, physicians tend to know what is best for their patients and therefore do not advise them to be candidates for an RCT. Furthermore, of all patients screened, only a minority is included in an RCT; thus, a highly selected population is studied, which does not reflect the patients we care for every day. This was for instance shown in the SYNTAX RCT (CABG vs PCI in multivessel disease), in which only a small percentage of the patients presented to the Heart Team was eventually randomised in the study [2]. In addition, we argue that patients with variables such as cancer, dementia or frailty are unlikely to be randomised in such a trial for reasons listed above. The fact that, as of today, an RCT has not been performed in the elderly, demonstrates the complexity