In the USA, among patients 65 years or younger, 75% of those with acute coronary syndrome (ACS) receive percutaneous coronary intervention (PCI) according to the National Registry for Myocardial Infarction (NRMI).1 These high figures contrast markedly with PCI rates among older patients. In the elderly population, only 40% of patients older than 75 years of age receive reperfusion therapy.1 Somewhat consistent with these low US figures, a recent study in England found an incremental reduction in the use of invasive and medical therapies with increasing age.2

The current American College of Cardiology/AHA guidelines and ESC guidelines do not suggest any age limitation in the use of PCI in management of ACS.3 ,4 The ESC guidelines suggest that the invasive strategy and PCI show increased benefit in older patients.4 The randomised clinical trials, however, provide limited data in relation to management of ACS in elderly patients. Most of the large PCI trials specifically excluded older patients, and when all clinical trials are considered, only about 9% of enrolled patients are older than 75 years, where in actual clinical practice about 35% of patients presenting with ACS are older than 75 years.1 In addition, the baseline characteristics of the older patients in clinical trials are different from the older population in the community.4 The patients in …