Patients older than 75 years represent about one third of those admitted to the Italian coronary care units due to an acute coronary syndrome, with a greater prevalence of the form without ST-segment elevation. Compared to younger patients, the elderly have higher risk characteristics and more adverse outcomes, particularly mortality and heart failure. Despite this, they receive less effective treatments, and especially less coronary reperfusion therapy. This attitude is only partially motivated by the fear of the potential adverse effects of antithrombotic and invasive treatments in the elderly, on the basis of misleading meta-analyses and observational studies. A more objective approach is taking fuel by recent randomized studies showing that the treatment effect is even greater in the elderly (particularly when evaluated in terms of "number of lives saved"), whereas the benefit is often hardly seen in the younger population. Also, the idea that the elderly may have little room for percutaneous coronary intervention has been progressively wiped away by the experience of those Centers that have started systematic coronary angiography regardless of the patients' age. The presence of severe copathologies has been often considered to limit intervention in the elderly. This real difficulty (although more typical of the seventh and eighth decade than at older age) should be rather considered specifically and not as a mere consequence of age. The elderly patient is at higher risk of iatrogenic bleeding: therapeutic regimens should be adjusted specifically in order to reduce this untoward effect of effective treatments.