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Older patients with cardiovascular disease face a high burden of thromboembolic disease but are often underrepresented in clinical trials. Biological aging increases both thrombotic and bleeding risk. Individualized strategies, such as risk scores, procedural choices, medication selection, and improvements in medication adherence are essential across conditions like acute coronary syndrome, atrial fibrillation, and venous thromboembolism. Direct oral anticoagulants are generally safer than vitamin K antagonists but require dose adjustment in older adults. When bleeding occurs, prompt management and carefully timed anticoagulation resumption are critical. A balanced, patient-centered approach remains key to optimizing outcomes in this complex, high-risk population.