The mean age of patients presenting with acute coronary syndrome (ACS) has been increasing steadily in the last decades, so managing very old patients has become common practice. The oldest patients are under-represented in clinical trials, so specific evidence is scarce. Still, antithrombotic therapy and invasive strategy are the pillars of appropriate treatment even in the oldest patients. However, the elderly population is a heterogeneous group showing important divergences between chronological and biological age, which needs specific evaluation. Physical, and social function, geriatric syndromes, such as frailty or cognitive decline, and comorbidities must be taken into consideration for clinical decision-making but this requires evaluation beyond the traditional cardiologic approach. In general, elderly patients with ACS who are functional and independent should be treated with the same methods as younger patients although more cautiously. However, specific measures should be put in place to prevent functional decline and delirium, two of the most frequent and devastating specific complications in older patients. Multidisciplinary approaches are needed for that. In general, a new paradigm for the management of very old patients with ACS is warranted, in which evaluation of outcomes traditionally ignored by cardiologists should be considered.