AIMS: To test the hypothesis that increasing age in patients presenting with high-risk non-ST-segment elevation acute coronary syndromes (NSTE-ACS) does not adversely influence the benefit of an early invasive strategy on major adverse events at 6 months. METHODS AND RESULTS: We report clinical outcomes in young (<70), elderly (70-80), and very elderly (>80 years) patients with high-risk NSTE-ACS enrolled in GRACE between 1999 and 2006. Six month data were available in 18 466 patients (27% elderly, 16% very elderly). Elderly and very elderly patients were less likely to receive evidence-based treatments at discharge and had a longer hospital stay (6 vs. 5 days). Angiography was performed more frequently in younger patients (67 vs. 33% in very elderly, 55% in elderly; P < 0.0001). Multiple logistic regression analysis confirmed the benefit of revascularization on the primary study endpoint (6-month stroke, death, myocardial infarction) in young [odds ratio (OR) 0.69, 95% confidence interval (CI) 0.56-0.86], elderly (0.60, 0.47-0.76), and very elderly (0.72, 0.54-0.95) patients. Revascularization was associated with reductions in 6-month mortality (OR 0.52, 95% CI 0.37-0.72 in young; 0.38, 0.26-0.54 in elderly; 0.68, 0.49-0.95 in very elderly). Stroke risk in hospital or at 6 months was not increased by revascularization. CONCLUSION: Following presentation with high-risk NSTE-ACS, an evidence-based approach to management was noted less frequently with advancing patient age. Angiography, in particular, was less likely to be undertaken. Revascularization, however, when performed, was associated with significant benefits at 6 months, independent of age, and did not increase risk of stroke.