Inflammaging and Acute Coronary Syndrome in Elderly Patients: Pathophysiological Mechanisms, Therapeutic Implications and Future Perspectives

Acute coronary syndrome (ACS) is a major cause of morbidity and mortality among elderly patients, whose increasing numbers have contributed to the growing burden of cardiovascular disease. Advanced age is associated with complex clinical presentations, multimorbidity, frailty, and poorer outcomes after ACS. Beyond traditional cardiovascular risk factors, chronic low-grade inflammation, or “inflammaging,” is increasingly recognized as an important contributor to atherosclerosis and cardiovascular events in older adults. Inflammaging involves persistent activation of the innate immune system, increased pro-inflammatory cytokines, oxidative stress, endothelial dysfunction, and immune dysregulation. These processes promote atherosclerotic plaque formation and destabilization, enhance thrombogenicity, and impair vascular repair, thereby increasing ACS risk. Immunosenescence further modifies inflammatory and immune responses and may influence disease progression and treatment effectiveness. Management of ACS in elderly patients is challenging because of atypical presentations, bleeding risk, polypharmacy, renal impairment, frailty, and limited representation in clinical trials. Current strategies emphasize individualized antithrombotic therapy, appropriate invasive management, comprehensive geriatric assessment, and consideration of anti-inflammatory treatments targeting residual inflammatory risk. This narrative review examines the relationship between inflammaging and ACS in elderly patients, focusing on pathophysiological mechanisms, inflammatory biomarkers, clinical implications, therapeutic approaches, and future perspectives, including personalized medicine, novel anti-inflammatory agents, and improved risk stratification by making a comprehensive literature search of the articles published between January 2000 and March 2026.