The heterogeneity of clinical presentation, response to treatment, and prognosis in elderly patients with acute coronary syndromes (ACS) is widely recognized. In patients >85 years, typical chest pain occurs in only 40% of cases compared with 77% in patients <65 years. Older patients more frequently complain of dyspnea, diaphoresis, nausea, vomiting, and syncope. ACS in older patients commonly presents as worsening heart failure (40% vs 20% in patients <65 years). The electrocardiogram on presentation is nondiagnostic in 23% of patients aged <65 years, increasing twofold in a subgroup of elderly patients aged >85 years. Diagnosis of ACS based on presenting symptoms can be more difficult because of a higher incidence of comorbid acute conditions that may mask the signs and symptoms of cardiac ischemia...