The Conservative treatment group had higher in-hospital mortality compared to invasive group (17.3% vs. 8.3%; p = 0.1108). Subgroup analysis of EIS showed statistically significant one-year mortality difference between Trans-Radial PCI and Trans-Femoral PCI (9.3% vs. 35.3%; p = 0.0157).Conclusion This retrospective data analysis study shows that early invasive strategy, though underutilized in octogenarians with ACS, is technically feasible with successful coronary revascularization in the majority of patients and appears superior to conservative strategy in terms of MACE by one year. Compared with the conservative strategy, early invasive treatment in octogenarians with ACS was associated with low in-hospital mortality, six and twelve-month all-cause mortality and twelve-month cardiac mortality.