Invasive strategy in elderly patients with acute coronary syndrome in 2018: close to the truth?

Elderly population constitutes an increasingly larger proportion of patients admitted for acute coronary syndromes (ACS). The optimal management of ACS in these patients is still a challenge due to their clinical peculiarities and the paucity of specific data, and they have been traditionally managed more conservatively mainly based on subjective criteria. In ST-segment elevation acute myocardial infarction urgent reperfusion is the standard of care and there is no upper age limit. In non-ST segment elevation acute myocardial infarction evidence is controversial, incomplete and mainly focused on chronological age. While a strict conservative strategy should be avoided, routine invasive strategy may reduce the occurrence of myocardial infarction and need for revascularization at follow-up with no established benefit in terms of mortality. Clinical characteristics associated with aging, such as comorbidities and frailty, further discriminate patient's risk beyond age. Evidence is scarce, but it suggests that these features may modulate the benefit of invasive strategy in this population. Ongoing trials should clarify the optimal management of ACS based on these parameters.