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Introduction Sex-based differences in percutaneous coronary intervention (PCI) outcomes are well described. Women are less likely to receive invasive management in acute and chronic coronary syndrome settings. Frailty, more prevalent among older women, is associated with increased mortality and adverse events after PCI. However, in elderly patients, the interplay between presentation, anatomical complexity, and short- and longer-term outcomes remains unclear. We evaluated sex differences in clinical presentation, procedural complexity, and outcomes following PCI in patients aged ≥80 years.Methods We performed a single-centre, retrospective analysis of 868 all-comer patients aged ≥80 years old who underwent PCI between 2017 and 2023, representing 13.3% of all patients treated in this period. Baseline characteristics, including comorbidities, Rockwood Clinical Frailty Score, SYNTAX score and angiographic calcification severity score, were collected. We analysed differences in procedural outcomes, in-patient complications, and MACE at discharge and at 12 months between men and women in this cohort.Results Women represented 32.4% of the sample (n=281). Women undergoing PCI were older than men (median age 84 vs 83, p=0.040). Women were more likely to undergo PCI in acute than elective setting (women vs men, elective 20.3% vs 34.2%, acute 74.7% vs 65.7%, p=0.005). Frailty distributions differed significantly between men and women on unadjusted analysis (p=0.010) ( figure 1). In the main-effects model adjusting for clinical syndrome, female sex remained independently associated with greater frailty (OR 1.30, p = 0.048). There was also a significant difference in distribution of SYNTAX score categories (low, intermediate, high) between men and women, with women exhibiting a greater proportion of low SYNTAX scores (p=0.005). The distribution of coronary calcification severity did not differ significantly between men and women (p = 0.301). The distribution of residual SYNTAX score did not differ significantly between men and women (p = 0.301), indicating comparable levels of revascularisation. Women were more likely to suffer inpatient MACE (8.9% vs 4.7%, p=0.017), but there was no difference in 12-month MACE or 12-month mortality (women vs men, 12.1% vs 17.0%, p=0.059 and 11.4% vs 11.9%, p=0.818, respectively).Conclusions In this real-world cohort of octogenarians undergoing PCI, women presented at older age, with greater frailty and more frequently in the acute setting, yet with less complex coronary anatomy and comparable revascularisation completeness to men. Despite higher rates of inpatient MACE, women demonstrated similar 12-month MACE outcomes, suggesting that short-term vulnerability does not translate into excess longer-term risk. These findings suggest frailty rather than anatomical complexity as a key driver of early adverse events in elderly female patients and underscore the importance of incorporating frailty assessment into procedural decision-making.Abstract 272 Figure 1Distribution of rockwood clinical frailty scores by sex