Coronary heart disease remains the leading cause of death in the developed world. Advanced age is the single strongest risk factor for coronary artery disease (CAD) and independent predictor for poor outcomes following an acute coronary syndrome (ACS). ACS refers to a spectrum of conditions compatible with acute myocardial ischemia and/or infarction due to various degrees of reduction in coronary blood flow as a result of plaque rupture/erosion and thrombosis formation or supply and demand mismatch. Unstable angina and non -ST segment elevation myocardial infarction are often continuous and clinically indistinguishable, collectively referred as non -ST elevation ACS (NSTE-ACS). An abrupt total occlusion of a coronary artery causing transmural myocardial ischemia/necrosis and displaying ST segment elevation or new left bundle branch block on a12-lead electrocardiogram (ECG) leads to the diagnosis of ST segment elevation myocardial infarction (STEMI). NSTE-ACS and STEMI require acute cardiac care. Professional societies have established guidelines for high quality contemporary care for ACS patients, i.e. American Heart Association/American College of Cardiology guidelines for STEMI1 andNSTE-ACS2, European Society of Cardiology guidelines for STEMI3 and NSTE-ACS4, and the United Kingdom National Institute for Health and Care Excellence (NICE) guidelines for STEMI5 and NSTE-ACS.6 Implementation of evidence-based therapies has significantly decreased mortality and morbidities of ACS.3, 7, 8 However, these advancements in ACS management have not equally improved outcomes for older adults. Vulnerable older patients continue to be at high risk of poor outcomes, are less likely to receive evidence based care, and have high mortality rates regardless of treatments given.9, 10 These disparities and challenges in caring for ACS in older adults are well recognized.11-13 This review summarizes the increasing burden and persistent unfavorable outcome of ACS in older adults, and discusses the clinical presentation, diagnosis and strategies for medical and invasive therapy.