The value of invasive therapy in elderly patients with acute myocardial infarction is controversial. The authors performed a retrospective chart review of 140 consecutive patients 80 years and older who were hospitalized with acute myocardial infarction. Hospital outcomes and long-term survival were compared in 79 patients referred for cardiac catheterization during hospitalization with outcomes in 61 patients managed conservatively. Vital status as of December 2003 was determined from the Social Security Death Index. Propensity analysis was used to limit confounding from 13 variables. After a mean follow-up of 333 days, unadjusted mortality was lower in the invasive group (16.5% vs 50.8%; P<.001). The multivariable propensity-adjusted hazard ratio for death was 0.30 (95% confidence interval, 0.11–0.76; P=.01), favoring the invasive group. These data suggest that in patients 80 years and older who are hospitalized with acute myocardial infarction, an invasive strategy confers a significant survival advantage during the first year after hospital discharge.