In western countries approximately a quarter of the population is 65 years and older. People in this age group often have several coexisting medical problems and take multiple drugs, and older people receive the greatest proportion of dispensed prescriptions. The prevalence of cardiovascular diseases, the leading cause of death and a major cause of physical and cognitive disability, increases steeply with increasing age. Drugs for the prevention and treatment of cardiovascular conditions account for a large proportion of medication prescription in older persons. Despite a number of published guidelines and expert recommendations supporting a standardized use of many cardiovascular agents, there is growing evidence of a tremendous variability in cardiovascular drug prescriptions according to demographics, health characteristics, and setting of care. In particular, evidence shows an inverse relationship between treatment propensity and age. To date, there is little evidence of benefit of most pharmacotherapy in frail, older subjects or elderly individuals with multiple comorbidities and polypharmacotherapy. However, effective treatment should not be denied solely on the basis of age. A major challenge in geriatric practice is to ensure safe and effective pharmacological treatments, avoiding the risk of polypharmacy and inappropriate drug prescription.