Beyond Chronological Age: Frailty, Vulnerability, and Invasive Decision-Making in Older Adults with Acute Coronary Syndromes

Older adults represent a growing proportion of patients presenting with acute coronary syndromes (ACS), yet they remain a highly heterogeneous population in terms of biological reserve, comorbidity burden, functional status, cognitive performance, and recovery potential. Chronological age alone is an insufficient basis for invasive decision-making, as it may lead to both therapeutic nihilism and disproportionate treatment escalation. Frailty has emerged as a clinically meaningful construct that captures vulnerability to acute stressors and may refine prognostic assessment beyond traditional cardiovascular risk scores. In ACS, frailty is associated with mortality, bleeding, procedural complications, delirium, functional decline, readmission, and loss of independence. However, frailty should not be interpreted as an automatic contraindication to invasive management. Rather, it should inform proportional care by integrating ischemic risk, procedural burden, reversibility potential, patient preferences, and expected quality of recovery. This narrative review examines the role of frailty assessment in older adults with ACS, focusing on its implications for invasive decision-making. We discuss frailty tools, clinical outcomes, therapeutic bias, healthcare inequities, and patient-centered endpoints. Finally, we propose a vulnerability-based framework for cardiovascular care, in which frailty guides individualized therapeutic intensity rather than justifying age-based exclusion from evidence-based treatment.