Older patients with NSTE-ACS benefit as much or more than younger patients from an early invasive strategy com- pared with an ischemia-guided strategy.340,341,515,518,519 In a 5-year follow-up meta-analysis of FRISC-II and RITA-3, an early invasive strategy versus an ischemia-guided strategy was associated with a significant reduction in death/MI and MI in patients 75 years of age but not in patients <65 years Although the highest risk reduction in death/MI with an early invasive strategy occurred in those 75 years of age, this strategy was associated with a 3-fold bleeding risk.552 However, despite the overall favorable evidence for an early invasive strategy in older patients, age is the strongest risk fac- tor for this group not undergoing an early invasive strategy.553 PCI has increased in older patients, including the very elderly ( 90 years of age), with success rates similar to younger patients and declining complication rates, including Several large registries report a greater RR reduction in mortality of older patients treated with revascularization versus medical therapy compared with those 65 years of age, despite increased comorbidities.517,540,554 556 Operative mortality rates for CABG in patients 80 years of age with NSTE-ACS range from 5% to 8% (11% for urgent cases) and increase to approximately 13% at 90 years of age. Complications occur more frequently in older patients with Length of stay averages 6 days longer in older patients than in patients <50 years of age, and discharge (to home [52%]) is less frequent than in younger patients.557 In a metaanalysis, off-pump CABG appeared to offer a poten- tially safer and more effective revascularization technique compared with on-pump CABG in older patients with NSTE- Older patients with NSTE-ACS with diabetes mellitus had a greater survival advantage with CABG.529 Evaluation tools can help identify older patients with NSTE-ACS whose risk and comorbidity profile predict mortality within 6 to 12 months and possibly guide a palliative approach.524 See Online Data Supplement 24 for additional information on older patients. 