Objective：To investigate the correlation between frailty status and disease severity in elderly patients with coronary artery syndrome（CAS），and to analyze risk factors in this population. Methods：This analytical cross - sectional study included 187 elderly patients diagnosed with CAS at the First Affiliated Hospital of Nanjing Medical University from September 2023 to September 2024，who underwent coronary angiography and intervention. Participants were divided into non-frailty（n=74），pre-frailty（n=72），and frailty groups（n=41）using the FRAIL scale. Coronary lesion severity was assessed by Gensini score. All patients underwent echocardiography to evaluate cardiac structure and function. High Gensini score was defined as ＞43 points using the tertile method， followed by univariate screening and multivariate regression modeling to identify risk factors. Restricted cubic splines were applied to test nonlinear relationships. Results：The pre -frailty and frailty groups had higher mean age and increased proportion of New York Heart Association（NYHA）class Ⅲ heart function（P ＜ 0.05）. Atrial fibrillation and low glomerular filtration rates were more prevalent in frailty and pre -frailty groups compared to non -frailty group（P ＜ 0.05）. High Gensini scores occurred more frequently in frailty （36.6%）and pre - frailty（33.3%）groups than in non - frailty group（20.3%），without statistical significance（P ＞ 0.05）. Left atrial diameter progressively increased across non -frailty，pre -frailty，and frailty groups（P ＜ 0.05）. Left ventricular end -diastolic diameter was larger in pre-frailty than non-frailty（P ＜ 0.05）. Segmental wall motion abnormalities were higher in frailty（24.4%）and pre-frailty （38.9%）groups than in non-frailty group（17.6%，P ＜ 0.05）. Logistic regression identified hypertension，diabetes，fasting glucose，and segmental wall motion abnormalities as positively correlated with high Gensini scores（all P ＜ 0.05），while body mass index（BMI） showed negative correlation（OR=0.872，95% CI：0.775- 0.980，P=0.021）. Spearman analysis revealed weak negative correlation between BMI and Gensini scores（rs=- 0.161，P=0.028）. Restricted cubic splines indicated no significant nonlinear relationships between BMI and Gensini scores overall or within frailty subgroups（P ＞ 0.05）. Conclusion：Frailty status was not significantly associated with coronary lesion severity in elderly patients with CAS. However，frailty and pre -frailty status predisposed to cardiac structural abnormalities and impaired contractile function.