We appreciate the insightful comments of Buendía-Santiago et al. regarding our subgroup analysis of the MOSCA-FRAIL clinical trial, recently published in Revista Española de Cardiología.1 These authors raised 3 pertinent points.

First, we concur that the subjective nature of the Clinical Frailty Scale (CFS) may introduce inter-center variability. To mitigate this possibility, we encouraged local investigators to train the personnel responsible for geriatric assessments, ensuring that the same team conducted all evaluations. However, we did not assess the concordance and reproducibility of these examinations and, as a result, cannot exclude the possibility of variability. We acknowledge this limitation. However, other more robust frailty assessment methods, such as physical performance tests, are impractical for patients presenting with acute coronary syndrome at admission.

Second, patients with a CFS score of 4 are classified as vulnerable or prefrail. While not considered frail, they cannot be deemed entirely robust either, making their inclusion in the trial highly relevant.

Third, in the subgroup analysis of the RITA trial, the impact of invasive management was neutral in both the nonfrail and frail subgroups with respect to the primary endpoint (cardiovascular death or nonfatal myocardial infarction).2 This finding agrees with the lack of benefit observed for invasive management in frail patients in the MOSCA-FRAIL trial. Notably, compared with cardiovascular death or recurrent myocardial infarction, we focused on more clinically meaningful alternative endpoints for frail patients, such as the number of days alive and out of hospital and all-cause mortality.3,4 Indeed, noncardiac events outnumbered cardiac events in the MOSCA-FRAIL trial.

Several registries have consistently demonstrated poorer outcomes for frail patients with NSTEMI compared with their robust counterparts.5,6 In the absence of large randomized trials specifically targeting frail populations, the CFS may serve as a valuable ancillary tool for risk stratification, supporting the complex decision-making process in this challenging patient group.