Percutaneous coronary intervention (PCI) for an acute coronary syndrome often is deferred in the frail older adult due to concerns about the benefit versus risk in this patient group. In this issue of Heart, Professor Di Bari and colleagues (see page 1537) report an observational cohort study of 698 elderly patients who presented with an acute coronary syndrome. The Silver Code was used to provide a numerical score that predicts overall 1 year mortality in patients older than age 75 years based on age, gender, martial status, previous hospital admissions and the number of chronic medications. In this study, each point increase in Silver Code, was associated with an 11% lower likelihood of the patient being treated with PCI but a 10% higher one-year mortality. In addition, the relative benefit of PCI was higher in those with higher Silver Codes suggesting that increased background risk should not dissuade physicians from intervention in the setting of acute coronary syndrome (figure 1).

In the accompanying editorial, Drs. Mazhari and Kapur (see …