Introduction: Acute coronary syndromes (ACS) remain the leading cause of mortality in developed countries, particularly affecting older adults. Managing vulnerable patients - particularly those who are frail or have significant comorbidities such as anemia or chronic kidney disease (CKD) - is challenging due to the lack of evidence-based guidelines tailored to this group. Areas covered: This review explores the management of non-ST-elevation acute coronary syndrome (NST-ACS) with a focus on antithrombotic therapy, invasive strategies, and cardiac rehabilitation (CR). Special attention is given to patients with frailty, atrial fibrillation (AF), and CKD, recognizing their complexity. For this purpose, studies specifically addressing the management of elderly patients with NST-ACS were reviewed. Expert opinion: Optimal management of elderly patients with NSTE-ACS requires a personalized approach. Antithrombotic therapy should be individualized, avoiding rigid guidelines. Less potent antiplatelet agents (e.g. clopidogrel) combined with direct oral anticoagulants (DOACs) offer improved safety in patients with AF. Early invasive strategies can reduce adverse events but may carry procedural risks in frail individuals. Systematic comprehensive geriatric assessment (CGA) should guide decision-making; and multidisciplinary care is essential to improving outcomes. Home-based or hybrid CR programs still need to be widely implemented and the integration of caregivers into them can enhance outcomes.