The elderly comprise a growing segment of the population and present special challenges for diagnosis and management that may lead to disparities in care and delays in treatment. Additional issues to consider include the risks of antithrom- botic and interventional therapies and the appropriate bound- aries of care within the context of individual comorbidities, frailty, and advanced-care directives. Clinical trials frequently have limited enrollment of older populations.37 Treatments that are effective in younger populations usually are indicated in the elderly, with the caveat that the elderly more often have absolute or relative contraindications to their use. Impaired renal function associated with aging requires careful attention to drug dosing.38,39 In an analysis of 8578 patients with STEMI from 226 US hospitals participating in the CRUSADE quality improvement initiative from September 2004 to December 2006, 7% of eli- gible patients did not receive reperfusion therapy.21 The factor most strongly associated with not providing reperfusion ther- apy in eligible patients was increasing age. Evidence suggests that even the very elderly have reasonable post-MI outcomes when treated aggressively with reperfusion therapy,40 though individual circumstances vary. Both the GWTG Quality Improvement Program and the North Carolina Reperfusion of Acute Myocardial Infarction in Carolina Emergency Department s initiative demonstrated that focused quality improvement efforts and programs designed to systematize care across integrated regional cen- ters can lessen disparities and improve the care of elderly patients with STEMI.23,41 Numerous studies have highlighted the fact that patients with chronic kidney disease of all stages less frequently receive guideline-recommended interventions than do patients with nor- mal renal function, despite evidence of benefit from most acute In a project that linked the US Renal Data System database with the NRMI (National Registry of Myocardial Infarction) 3, patients on dialysis had longer prehospital delays, werelessoftenrecognizedashavinganacuteMI,andlessoftenhad STelevationorLBBBoninitialECGthanpatientsnotondialysis. 