Background: Evaluation of acute appendicitis in the elderly presents a diagnostic challenge to the surgeon. The diagnosis is often difficult to establish on account of general poverty of history and clinical signs, comorbidity and the unreliability of diagnostic procedures. Due to this, morbidity and mortality statistics in this group of patients is unacceptably higher than the general population.Methods: Individual case report and literature review.Results: We present an unusual case of perforated appendicitis masquerading as acute coronary syndrome.Conclusions: Patient’s education, high index of suspicion, and an aggressive surgical approach is needed if the outcome among the elderly population is to be improved.