Demographic studies show an ever increasing number of subjects >65 years among the Italian population. In particular, subjects aged >75 years represent nowadays 9% of the Italian population and are expected to exceed 14% by 2030. In the district of Crema (Italy), subjects aged >75 years are 16 000, and are expected to reach 25 000 by 2030. This phenomenon will result in an increasing number of elderly patients with acute coronary syndromes (ACS) admitted to our hospital. It is therefore necessary to define appropriate guidelines for clinical management of this subset of patients, in order to pursue a reduction in mortality rates and rehospitalizations, while maintaining an acceptable quality of life. These strategies are not adequately supported by international guidelines or randomized studies, where advanced age often represents an exclusion criterion. In our Cardiology Unit, hemodynamic evaluation is performed in all patients >75 years presenting with ST-elevation myocardial infarction (STEMI), ACS, positive troponin I, recurrent episodes of heart failure associated with clinical and instrumental suspicion of ischemia, or in survivors of cardiac arrest without neurological deficit. In all patients, presence of comorbidities is also evaluated, in particular renal insufficiency, disabling cerebrovascular disease, and residual quality of life. From February 2011 to February 2012, 974 coronary angiographies and 692 coronary angioplasties (PTCA) were performed. Of these, 194 procedures were performed in patients ≥75 years, the remaining in younger patients. The reason for hospitalization was ACS in 71% of elderly patients versus 53% in younger patients. In elderly patients, drug-eluting stents were used in 30% of the procedures. PTCA was successful in 98% of cases. Main complications included major bleeding (0.8%), access site-related bleeding (all femoral) (2%), and arterial rupture (n = 1). From a technical viewpoint, the radial access was predominantly used (78%), single plain old balloon angioplasty was performed in 12% of the procedures, with tirofiban administration in 42% of cases. Periprocedural and in-hospital mortality was 5%, mainly occurring in patients with STEMI and/or diffuse coronary artery disease. During follow-up, 80% of patients achieved a fairly good quality of life; 15% of patients required rehospitalization for cardiovascular reasons. In conclusion, patient's age should not be regarded as the main key factor for decision-making when evaluating different clinical approaches to patients with ACS.