Objective: To evaluate the impact of increased age on outcome from a strategy of early invasive management and revascularisation in patients with acute coronary syndromes (ACS). Design: Retrospective analysis of a national Acute Coronary Syndrome registry (ACACIA). Setting: Multiple Australian (n=39) centres; 25% rural, 52% with onsite cardiac surgery. Patients: Unselected consecutive patients admitted with confirmed ACS, total n=2559, median 99 per centre. Interventions: Management was at the discretion of the treating physician. Analysis of outcome based on age >75 years was compared using Cox proportional hazard with a propensity model to adjust for baseline covariates. Main outcome measures: Primary outcome was allcause mortality. Secondary outcomes were bleeding and a composite of any vascular event or unplanned readmission. Results: Elderly patients were more likely to present with high-risk features yet were less likely to receive evidence-based medical therapies or receive diagnostic coronary angiography (75% vs 49%, p<0.0001) and early revascularisation (50% vs 30%, p<0.0001). Multivariate analysis found early revascularisation in the elderly cohort to be associated with lower 12-month mortality hazard (0.4 (0.2-0.7)) and composite outcome (0.6 (0.5-0.8)). Propensity model suggested a greater absolute benefit in elderly patients compared to others. Conclusions: Following presentation with ACS, elderly patients are less likely to receive evidence-based medical therapies, to be considered for an early invasive strategy and be revascularised. Increasing age is a significant barrier to physicians when considering early revascularisation. An early invasive strategy with revascularisation when performed was associated with substantial benefit and the absolute accrued benefit appears to be higher in elderly patients.