We appreciate the comments and interest from Gualis Cardona et al and Lozano et al regarding our study.1 Their comments support our impression that the results from our study can be extrapolated to most Spanish centers. They explained their opinions on the causes that have led to the infrequent use of coronary revascularization surgery in Spain. We would add to these causes the progressive increase in experience and confidence of the interventional cardiologists when it comes to treating lesions of the common trunk or multivessel disease, the advances in technology that have led to a low rate of restenosis and thrombosis, and patient preferences, particularly for patients of advanced age.

There is also a lack of published data on surgical results from hospitals in our environment and a low rate of procedures by some cardiac surgeons, owing to a low rate of referral. We think this could contribute to the perception some cardiologists have that the results of surgery in centers where practice is based on guideline recommendations are not comparable to results obtained nationwide.

However, our intention was not to perform an exhaustive analysis of the factors that have led to the situation we described, but to stress the need for their analysis.

During recent years it has been common to see studies and registers published in our environment that analyze rates of compliance with guidelines for such prevalent and relevant conditions as atrial fibrillation,2 acute coronary syndrome,3 hypertension,4 or hyperlididemia.5 However, we are not aware of any studies that have analyzed compliance with clinical guideline recommendations on coronary revascularization.

The lack of economic interest in promoting initiatives or support for this type of study should not be an impediment; the scientific societies and administrative bodies can and must encourage the conduction of such studies.

Finally, we would like to acknowledge the comments from Gualis Cardona et al. regarding our study opening the door to an essential debate in our country. Should this happen, we will consider the main objective of our study1 achieved.