Bivalirudin, rather than a GP IIb/IIIa inhibitor plus UFH, is reasonable in older patients** with NSTE- ACS, both initially and at PCI, given similar efficacy but less bleeding risk.396,526 528 (Level of Evidence: B) 2. It is reasonable to choose CABG over PCI in older patients** with NSTE-ACS who are appropriate can- didates, particularly those with diabetes mellitus or complex 3-vessel CAD (eg, SYNTAX score >22), with or without involvement of the proximal LAD artery, to reduce cardiovascular disease events and readmission and to improve survival.529 534 (Level of Evidence: B) In this CPG, older adults refers to patients 75 years of age.515 Older adults have the highest incidence, prevalence, and adverse outcomes of NSTE-ACS.9,515 517,535,536 Older age is accompanied by comorbidities, polypharmacy, and age- and disease-related physiological changes that adversely impact NSTE-ACS presen- tation, management, and outcome. As older patients are under- represented in clinical trials, the recommendations in this CPG are largely supported by registry data and meta-analyses.516,537 Older patients with NSTE-ACS primarily present with chest pain but frequently have atypical symptoms. 