Abstract Funding Acknowledgements Type of funding sources: None. Older patients with acute coronary syndrome (ACS) require a special management, taking into account comorbidity and gerontological syndromes. Obesity paradox and nutritional status as a factor of poor prognosis need further study. The aim of this study was to investigate nutritional statusin older patients with ACS and comorbidity. Materials and methods 90 older patients (51 males and 39 females, mean age was 67.0 ± 6.2 years) admitted to hospital with ACS were studied. ACS with ST-segment elevation (STE-ACS) and without ST segment elevation (NSTE-ACS) were diagnosed according to ESC Guidelines (2017 and 2015, respectively). STE-ACS was diagnosed in 17 (18.9%) patients, NSTE-ACS - in 73(81.1%) patients. All patients had cardiovascular pathology before hospitalization: 86 (95.6%) patients had arterial hypertension, 71 (78.9%) - coronary artery disease, 37 (41.1%) patients - myocardial infarction in history. Charlson comorbidity index (CCI) was estimated. Comorbidity was regarded as high at index ≥ 6 scores. Nutritional status was assessed: the presence of obesity, type of obesity, body composition, including percentage of lean and fat tissue. Quality of life, frailty syndromeand personal characteristics were evaluated. Results The CCI was 5.9 ± 1.9 scores. 50 (55.6%) older patients with ACS had high comorbidity. Half of patients (43; 47.8%) had frailty syndrome.Obesity was observed in33 (36.7%) patients, 52 (57.8%)hadoverweight,62 (68.9%)- abdominal obesity. 85 (94.4%) - had a higher percentage of fat tissue.Patients with ACS and high comorbidityhad lowertotal water volume (37.9 ± 5.1and40,8 ± 5.8 liters resp., p = 0,01) and lean body mass (51.9 ± 7.0and55,9 ± 7.5 kg resp., p = 0,01)and higherthe percentage of body fat(40.9 ± 8.9and35,8 ± 6.7 % resp., p = 0,01)compared to patients with low comorbidity. Olderpatientswith ACS andfrailty syndrome had higherthe percentage of body fat(43.9 ± 9.4and31,9 ± 6.3 % resp., p = 0,002)andlowerthe percentage of leanbody(62.9 ± 6.4and71,3 ± 4.9 % resp., p = 0,00008)compared to patients without frailty syndrome. There was a direct relationship between the level of anxiety and depression and the percentage of body fat( r = 0.45, p < 0.0001; r = 0.36, p = 0.001 resp.) and negative relationship with physical functioning (r=-0.46, p < 0.0001). Conclusions Older patients withACS are characterized byhigh comorbidity and frailty. Body composition is dependent on comorbidity: patients with ACS and high comorbidityhadlowertotal water volume, lean body massandhigher percentage of body fat(sarcopenic obesity)compared to patients with low comorbidity.