Gender Differences in Risk Factors, Management, and Outcomes of Elderly Patients With Acute Coronary Syndrome: The Interplay of Frailty

Backgrounds Older adults constitute a growing proportion of patients presenting with acute coronary syndrome (ACS); optimal management remains uncertain due to comorbidities, frailty, procedure‐related complications. Aim This study aimed to identify prognostic determinants and to evaluate the impact of invasive management strategies on short‐ and long‐term outcomes in elderly patients with ACS. Methods We retrospectively analyzed consecutive ACS patients aged ≥ 75 years who underwent coronary angiography. Frailty was assessed within the first 48 h of admission using the Rockwood Clinical Frailty Scale (CFS). Sex‐related differences, frailty, treatment strategies (percutaneous coronary intervention [PCI] vs. conservative/medical therapy), predictors of short‐ and long‐term outcomes were assessed. The primary endpoint was all‐cause mortality; secondary endpoints included major adverse cardiac and cerebrovascular events (MACCEs). Results A total of 627 patients were included (46% women), with non–ST‐elevation ACS (NSTE‐ACS) as the predominant presentation (66.8%). Patients presenting with ST‐elevation myocardial infarction (STEMI) experienced significantly higher in‐hospital mortality (19.7% vs.5.7%) and MACCEs rates (50.5% vs. 22%; both p < 0.001) compared with those with NSTE‐ACS. In‐hospital and 1‐year mortality did not differ by sex. Shock, frailty, contrast‐induced nephropathy, peak troponin levels as independent predictors of in‐hospital mortality, whereas frailty, reduced left ventricular ejection fraction, peak troponin independently predicted long‐term mortality. Among patients with NSTE‐ACS, PCI was associated with lower in‐hospital mortality (3.5% vs. 8.4%; p = 0.040) but higher rates of in‐hospital and long‐term adverse events, without a significant reduction in 1‐year mortality. Conclusions Frailty is a dominant determinant of both short‐ and long‐term mortality and should be systematically incorporated into early risk stratification. A selective, frailty‐guided invasive strategy may improve early survival whereas routine intervention appears unjustified given the lack of long‐term benefit and increased complication risk.