Background: ESC recommends ticagrelor over clopidogrel for the treatment of acute coronary syndrome (ACS) but the lack of evidence for elderly patients (≥75) and concerns over bleeding has led to significant variability in its use within the UK. Our aim is, therefore, to compare the safety of ticagrelor compared to clopidogrel in real-world elderly patients admitted with ACS and managed either medically or through percutaneous intervention. Methods: Unselected elderly patients (≥75) admitted to Royal Berkshire Hospital with ACS (2013–2015) were identified and followed for 1 year. The primary outcomes were bleeding events (TIMI criteria), all-cause mortality, cardiovascular mortality, ischemic stroke, angina, NSTEMI and STEMI. Results: A total of 288 patients with ACS were discharged with aspirin and either clopidogrel (137) or ticagrelor (151). In total, 152 of these patients underwent invasive angiography and revascularization. The baseline clinical characteristics and crusade bleeding score were similar between the groups receiving ticagrelor or clopidogrel. There were no significant differences in all-cause mortality (8.8% vs. 10.6%), cardiovascular mortality (2.9% vs. 2.0%), ischemic stroke (0.7% vs. 2.0%), angina (6.6% vs. 5.3%) or STEMI (2.2% vs. 1.3%). Patients on clopidogrel, however, had increased events of NSTEMI compared to ticagrelor (8.0% vs. 2.0%, OR 4.481, 95% CI 1.223–16.42) and overall MI (10.2% vs. 3.3%, p = 0.030). No difference was observed in either major (8.8 vs. 8.6%) or minor TIMI bleeding (18.2% vs. 20.5%) and after propensity score matching (minor bleeding p = 0.39, major bleeding p = 0.76). Conclusions: In this real-world analysis, ticagrelor did not increase major or fatal bleeding compared to clopidogrel in elderly patients. In view of the mortality benefit in the large trials, additional cardiovascular benefit of ticagrelor should not be withheld on the basis of age as a perceived risk factor for bleeding in ACS.