Elderly patients with acute coronary syndromes suffer higher mortality and more morbidity than their younger counterparts because they have higher prevalence of cardiac risk factors and have lived with those risk factors longer, physiologic effects of aging lead to sicker patients at presentation and impaired healing processes, they are more sensitive to some of the side effects of some of our higher risk therapies, and they are less likely to receive therapies that have been proven to improve outcome. Close attention must be paid to risk assessment. We must continue to strive to match risky therapies to high-risk patients, those more likely to derive benefit. Age remains one of the most powerful cardiac risk factors of all.