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Background: Reduced estimated glomerular filtration rate (eGFR) is associated with lower use of invasive management and increased mortality after acute coronary syndrome (ACS). The reasons for this are unclear., Methods: A retrospective clinical cohort study was performed using data from the English National Institute for Health Research Health Informatics Collaborative (2010-2017). Multivariable logistic regression was used to investigate whether eGFR<90 mL/min/1.73 m 2 was associated with conservative ACS management and test whether (a) differences in care could be related to frailty and (b) associations between eGFR and mortality could be related to variation in revascularisation rates., Results: Among 10 205 people with ACS, an eGFR of <60 mL/min/1.73m 2 was found in 25%. Strong inverse linear associations were found between worsening eGFR category and receipt of invasive management, on a relative and absolute scale. People with an eGFR <30 mL compared with ≥90 mL/min/1.73 m 2 were half as likely to receive coronary angiography (OR 0.50, 95% CI 0.40 to 0.64) after non-ST-elevation (NSTE)-ACS and one-third as likely after STEMI (OR 0.30, 95% CI 0.19 to 0.46), resulting in 15 and 17 per 100 fewer procedures, respectively. Following multivariable adjustment, the ORs for receipt of angiography following NSTE-ACS were 1.05 (95% CI 0.88 to 1.27), 0.98 (95% CI 0.77 to 1.26), 0.76 (95% CI 0.57 to 1.01) and 0.58 (95% CI 0.44 to 0.77) in eGFR categories 60-89, 45-59, 30-44 and <30, respectively. After STEMI, the respective ORs were 1.20 (95% CI 0.84 to 1.71), 0.77 (95% CI 0.47 to 1.24), 0.33 (95% CI 0.20 to 0.56) and 0.28 (95% CI 0.16 to 0.48) (p<0.001 for linear trends). ORs were unchanged following adjustment for frailty. A positive association between the worse eGFR category and 30-day mortality was found (test for trend p<0.001), which was unaffected by adjustment for frailty., Conclusions: In people with ACS, lower eGFR was associated with reduced receipt of invasive coronary management and increased mortality. Adjustment for frailty failed to change these observations. Further research is required to explain these disparities and determine whether treatment variation reflects optimal care for people with low eGFR., Trial Registration Number: NCT03507309., Competing Interests: Competing interests: YB-S is partly funded as the Data Science co-lead by the National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) and University of Bristol. RL reports funding unrelated to this work from the Royal Marsden Cancer charity, Cancer Research UK, Innovate UK (co-funded by Roche), RM Partners Cancer Alliance, the NIHR and NHS England and consulting fees from Royal Marsden Private Care for personal private practice and is NHS England Joint National Clinical Lead for the Targeted Lung Health Check Programme and NIHR Clinical Research Network National Specialty Lead for Screening, Prevention and Early Detection., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)