In reply: We thank Pearson for her kind comments and agree the design of our study1 prevented identification of all patient factors that may, quite reasonably, impact on clinicians' decisions to administer specific treatments to older patients with acute myocardial infarction (AMI). These factors may also have precluded such patients from enrolment in clinical trials, the results of which underpin recommendations within clinical practice guidelines.

On the other hand, we know advancing age is an independent predictor of increased mortality after AMI, with several possible causes: age-related reductions in protective mechanisms (such as myocardial preconditioning),2 presence of cardiac and non-cardiac comorbidities unaffected by treatments for AMI,3 and — the focus of our study — underuse of effective therapies in the absence of discernible contraindications.4,5 While cognitive impairment, renal dysfunction and poor functional status may dissuade patients and/or clinicians from pursuing "aggressive" management, we have no evidence that these factors, singly or in combination, necessarily attenuate the benefits of specific interventions for AMI in patients at high baseline risk of cardiac death.6 We also adjusted mortality comparisons between concordant- and discordant-care groups for multiple measures of illness severity at presentation which predict a poor prognosis.

Nevertheless, we support calls for more randomised trials of treatments for AMI and other conditions in older patients with liberal, "real-world" inclusion criteria in determining absolute risks and benefits of intervention in the presence of multiple comorbidities and impaired function.