Abstract Background In patients with ischaemic heart disease (IHD) aged > 70 years, Dutch and European guidelines recommend different treatment targets: low-density lipoprotein cholesterol (LDL-c) < 2.6 versus < 1.4 mmol/l and systolic blood pressure (SBP) < 140 versus < 130 mm Hg, respectively. How this impacts cardiovascular event-free life expectancy has not been investigated. The study objective was to compare estimated lifelong treatment benefits of implementing Dutch and European LDL‑c and SBP targets. Methods Data from patients aged 71–80 years hospitalised for IHD in 2017–2019 were extracted from the PHARMO Database Network, which links primary and secondary healthcare settings, with follow-up until 31 December 2020. Potential benefit according to treatment strategy (in gain in event-free years) was estimated using the SMART-REACH model. Results Of the 3003 eligible patients, 1186 (39%) had missing LDL‑c and/or SBP measurements. Of the 1817 included patients (36% women, median age at event: 74 years (interquartile range (IQR): 72–77), 84% achieved the Dutch targets for both LDL‑c and SBP; for European targets, this was 23% and 61%, respectively. If Dutch targets were met for LDL‑c and SBP ( n = 1281), the additional effect of reaching European targets was a median gain of 0.6 event-free life years (IQR: 0.3–1.0). The greatest effect could be reached in patients not reaching Dutch targets ( n = 501), with a median gain of 0.6 (IQR: 0.2–1.2) and 1.7 (IQR: 1.2–2.5) event-free years with Dutch versus European targets. Conclusion In patients aged > 70 years with IHD, implementation of European targets resulted in a greater gain of event-free years compared with Dutch targets, especially in patients with poorer risk factor control. The considerable number of patients with missing risk factor documentation suggested additional opportunities for risk reduction.