{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T09:28:53Z","timestamp":1786958933808,"version":"build-2736575974"},"reference-count":65,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T00:00:00Z","timestamp":1786924800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100004587","name":"Instituto de Salud Carlos III","doi-asserted-by":"publisher","award":["JR22\/00004"],"award-info":[{"award-number":["JR22\/00004"]}],"id":[{"id":"10.13039\/501100004587","id-type":"DOI","asserted-by":"publisher"}]},{"award":["JR22\/00004"],"award-info":[{"award-number":["JR22\/00004"]}],"id":[{"id":"https:\/\/ror.org\/00ca2c886","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Geriatrics"],"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.3390\/geriatrics11040106","type":"journal-article","created":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T08:05:41Z","timestamp":1786953941000},"page":"106","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Beyond Chronological Age: Frailty, Vulnerability, and Invasive Decision-Making in Older Adults with Acute Coronary Syndromes"],"prefix":"10.3390","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7914-9788","authenticated-orcid":false,"given":"Lourdes","family":"Vicent","sequence":"first","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1038-9710","authenticated-orcid":false,"given":"Rafael","family":"Salguero-Bodes","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"},{"name":"Facultad de Medicina, Universidad Complutense, 28041 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-2262-1222","authenticated-orcid":false,"given":"Pablo R.","family":"Alonso","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-1696-6096","authenticated-orcid":false,"given":"Helena","family":"Alarcos","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elena","family":"Puerto Garc\u00eda-Mart\u00edn","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"},{"name":"Comit\u00e9 de \u00c9tica de la Investigaci\u00f3n con Medicamentos, Hospital 12 de Octubre, 28041 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlos","family":"Diaz-Arocutipa","sequence":"additional","affiliation":[{"name":"Unidad de Revisiones Sistem\u00e1ticas y Meta-An\u00e1lisis (URSIGET), Vicerrectorado de Investigaci\u00f3n, Universidad San Ignacio de Loyola, Lima 15024, Peru"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fernando","family":"Arribas Ynsaurriaga","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"},{"name":"Facultad de Medicina, Universidad Complutense, 28041 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roberto","family":"Mart\u00edn-Asenjo","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"},{"name":"Facultad de Medicina, Universidad Complutense, 28041 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,17]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e6","DOI":"10.1161\/CIR.0000000000000741","article-title":"Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement from the American Heart Association","volume":"141","author":"Damluji","year":"2020","journal-title":"Circulation"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1726","DOI":"10.1093\/eurheartj\/ehu197","article-title":"Importance of Frailty in Patients with Cardiovascular Disease","volume":"35","author":"Singh","year":"2014","journal-title":"Eur. 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