OBJECTIVES: To evaluate an early invasive strategy in elderly patients with non-ST elevation acute coronary syndrome (ACS). METHODS: All consecutive patients admitted with a diagnosis of non-ST elevation ACS from June 2002 to February 2004 were enrolled in this registry. Clinical outcome was assessed at 30 days and in long term follow up. RESULTS: An early invasive strategy was followed for 439 patients, of whom 159 (36%) were elderly and had a higher clinical risk profile and greater extent of coronary artery disease (CAD) than the younger patients. Coronary revascularisation was conducted in 133 (83%) elderly patients and 239 (85%) younger patients (not significant). At a mean (SD) follow up time of 10.7 (5.2) months overall mortality, cardiac death, and death plus myocardial infarction were significantly higher among elderly patients than among younger patients (9.4% v 2.1%, p < 0.001; 6.8% v 1.8%, p < 0.01; 11.3% v 5%, p = 0.02, respectively). The significant difference in cardiac death between the two groups was related more to elderly patients being treated by coronary artery bypass grafting (19.3% v 4.9%, p = 0.05) than by percutaneous coronary intervention (PCI) (2.9% v 1.1%, p = 0.3). Cox regression analysis showed age, serum creatinine > 115 micromol/l, no previous history of CAD, left ventricular ejection fraction > 45%, and the absence of diabetes to be independent predictors of the occurrence of major adverse cardiac events. CONCLUSIONS: In unselected elderly patients presenting with non-ST elevation ACS an early invasive strategy is feasible and leads to coronary revascularisation in the majority of cases, resulting in encouraging immediate and long term clinical results, particularly among PCI treated patients.