The elderly are a rapidly growing segment of the population with a high likelihood of acute coronary disease and worse outcomes after acute coronary syndromes than younger groups. Although underrepresented in clinical trial populations, they benefit to an equal or greater extent from treatment with proven medications and interventions, and survivors to hospital discharge have excellent longer term functional outcomes. With consideration of individual preferences for treatment and inherent risks for side-effects in this population, age alone should not determine management of elderly acute coronary syndrome patients.