Background: Using decision aid rules for diagnosis of acute myocardial infarction (AMI) is not common practice in our region. Elderly patients are often neglected in clinical trials, and the proper diagnostics of acute myocardial infarction in this group remains problematic. The objective of this study was to evaluate the accuracy and effectiveness of different strategies for the diagnosis of AMI in the elderly in real-life clinical practice. Methods: In a retrospective single-center study, we included patients older than 70 years presenting to the emergency department with chest pain as a dominant symptom. The performance of six decision aid rules (T-MACS, HEART, EDACS, TIMI, GRACE, and ADAPT) and solo troponin T strategy for diagnosing acute myocardial infarction was evaluated by calculating sensitivity, specificity, odds ratios, negative and positive predictive values.Results: A total of 250 patients, with a mean age of 78.5 years, were enrolled. Forty-eight patients (19.2%) had an acute myocardial infarction in a 30 day follow-up period. The sensitivity for ruling-out AMI was 100% for T-MACS, HEART, and ADAPT; 97.9% for EDACS, 93.8% for TIMI, and 81.3% for GRACE and solo TnT strategy. For ruling-in AMI, the specificity was 97.5% for T-MACS, 95% for TIMI, 83.2% for HEART, 81.7% for GRACE, and 46% for ADAPT. C-statistics were 0.52 for T-MACS, 0.51 for ADAPT, 0.47 for EDACS and GRACE, 0.46 for HEART and TIMI, and 0.33 for solo TnT strategy.Conclusion: T-MACS decision aid had the best performance with 100% sensitivity and 100% negative predictive value for rule-out AMI; 97.5% specificity and 64.3% positive predictive value for rule-in AMI. Other evaluated protocols were less accurate. Risk stratification of patients with suspected acute coronary syndrome based on decision aid rules can be used in real-life practice, even in the population of the elderly.