Cardiovascular disease (CVD) is the most important contributor to overall mortality in the general population. More than half of all patients dying from CVD are older than 70 years. Prevention, diagnosis and management of coronary artery disease (CAD) in the elderly population differ in many respects compared to younger patients. Age per se can contribute significantly to overall global cardiovascular risk in the elderly population: in such cases when age is the sole risk factor for CVD, threshold for initiation of pharmacological intervention should be gauged carefully to balance possible side effects and clinical benefits. The use of non-invasive stress test for the diagnosis of CAD is limited by factors like co-morbidities, diminished exercise capacity, and false negative results due to high disease prevalence. While carefully considering possible drug side effects, one should not refrain from optimal medical therapy as recommended by evidence based guidelines in the elderly CAD patients. Biological age, rather than the calendar age, as well as frailty status should be considered while planning treatment in elderly CAD patients: involvement of the patient in the decision process would be beneficial while optimizing the treatment to attain the best risk/benefit ratio in geriatric CAD subjects.