Advanced age is not only a powerful predictor for the development of ischemic heart disease (IHD), it also becomes, in established IHD, the most important risk factor for morbidity and mortality. The reasons lie in the increased comorbidity and frequently atypical presentation of IHD in the elderly, making diagnosis more challenging and often delaying the initiation of therapy. Age-related changes in the cardiovascular system compound the risk by making compensation more difficult once ischemic damage occurs. Even though many randomized controlled trials have enrolled relatively few older patients, the management of acute coronary syndromes in this population should still be informed by the resulting guidelines. Therapy in older patients with acute coronary syndrome has to be balanced against their known propensity to bleeding risk. Dose adjustments based on creatinine clearance can optimize benefit and decrease this risk. Given the increase in morbidity and mortality with acute coronary syndromes in the elderly, aggressive risk factor modification is vital for decreasing recurrent events. Appreciation of the benefits of such therapies in the older patient with IHD will hopefully decrease the high morbidity and mortality risk...