Frailty is prevalent in older patients and those with cardiovascular disease. Frail patients are at increased risk of death, ischaemic events and bleeding complications following acute coronary syndrome, yet are less likely to receive evidence-based medications, coronary angiography or revascularisation. Frailty is associated with high-risk angiographic characteristics and complex coronary artery disease, whilst the presence or absence of frailty may influence any clinical benefit derived from revascularisation. Older patients with acute coronary syndrome are historically under-represented in clinical research and robust trial data investigating interventional strategies in frail patients is lacking. International treatment guidelines recognise the lack of consensus regarding the safety and effectiveness of invasive or conservative management strategies in frail older patients. Evaluation of outcomes which better reflect patients’ health goals—such as health-related quality of life—may be appropriate alongside conventional clinical endpoints.