The number of elderly patients requiring antithrombotic therapy (for example, those with atrial fibrillation, ischemic heart disease, peripheral arterial disease, or venous thrombo-embolism) is increasing worldwide due to population aging. These patients are often frail and therefore at increased risk of both thromboembolic events and bleeding complications during antithrombotic treatment. Therapeutic decision-making is further complicated by the underrepresentation of older adults in large randomized trials and the resulting scarcity of age-specific, evidence-based data. As a result, their management is not guided by specific recommendations but rather relies on clinician evaluation in an individualized, patient-by-patient approach. The aim of this narrative review is to discuss the current optimal therapeutic strategies for the management of elderly patients in different clinical conditions requiring antithrombotic therapy. We analyze the efficacy and safety of the different anti-thrombotic drugs and guidelines indications by discussing the clinical data available from randomized as well as observational studies. At the same time, we focus into the future of antithrombotic therapy presenting new drugs and new strategies for the management of elderly patients requiring antithrombotic therapy.