Context: The aim of study was to determine the difference in presentation, risk factors, complications, management and outcome of elderly and young patients with acute myocardial infarction (AMI). Settings and design: Tertiary care center; prospective observational study. Materials and method: The study included 200 consecutive patients with AMI admitted in the ICCU, in a tertiary care center in West India. The group I consisted of 107 patients aged equal to or above 65 years and the group II consisted of 93 patients aged below 65 years. Statistical analysis: Two tailed student’s t test and Chi-square statistics (Fisher’s test) for P value. Results: The male female ratio was 1.27:1 and 3.43:1 in group I and group II respectively. Atypical presentations were more likely in the elderly, with shortness of breath as the most common presentation (40.18% versus 15.05%; P < 0.05. Risk factors like hypertension, dyslipidemia and diabetes were equally present in both groups but obesity, smoking and family history of coronary artery disease was more prevalent in younger age group (P < 0.05). The elderly were significantly less frequently revascularized (P < 0.05). Time from symptom onset to hospital admission was significantly longer in the case of elderly patients (P < 0.05). The elderly were more likely to have complications of cardiac failure (P < 0.05) and arrhythmias especially atrio-ventricular (AV) blocks. The elderly were also less likely to receive betablockers (P < 0.05). In-hospital mortality was higher in the elderly (P < 0.001). Conclusion: We conclude that the manifestations of AMI are more subtle in the elderly, with different risk factors.