Elderly patients with ACS should not be denied invasive coronary angiography: pros and cons

The management of acute coronary syndromes (ACS) typically involves an invasive strategy, including coronary angiography and - eventually - myocardial revascularisation. However, this approach might be less beneficial or even contraindicated when the expected benefits are small or even outweighed by significant risks. It particularly holds true in elderly patients, who often present with frailty and multiple comorbidities. As life expectancy continues to increase, the number of elderly individuals presenting with ACS is growing, making it crucial to define the optimal treatment strategy for this population. The SENIOR-RITA Trial has shown that, despite reducing non-fatal myocardial infarction (MI), the invasive approach did not affect mortality in elderly patients with ACS, raising questions about the balance between the risks and benefits of such a strategy. Nonetheless, early invasive coronary angiography and myocardial revascularisation can improve clinical outcomes, symptoms and quality of life. Whether an invasive strategy should be routinely applied to elderly patients presenting with ACS or whether a more personalised approach should be prioritised remains a subject of debate.