Objectives This study aimed to investigate the impact of routine angiographic follow-up (RAF) on 3-year clinical outcomes in older patients (≥ 65 years) following percutaneous coronary intervention (PCI) with drug-eluting stents (DES) as compared with those of patients with clinical follow-up (CF). Methods This study enrolled a total of 3,147 patients aged 65 years and older, who had undergone PCI with DES. Among these patients, 1,313 (%) underwent RAF at 6–9 months post - PCI, while the remaining 1,834 patients were clinically followed. To address baseline clinical and angiographic differences between the two groups, propensity score matching (PSM) analysis was performed. The primary endpoint was major adverse cardiac events (MACE), which include cardiac death (CD), non-fatal myocardial infarction (MI), and target lesion revascularization (TLR). Additionally, we assessed the secondary endpoints that included CD, non-fatal MI, TLR, target vessel revascularization (TVR), non-target vessel revascularization (non - TVR), and stent thrombosis (ST). Results Following PSM, the 3-year cumulative incidence for TLR (hazard ratio [HR], 3.415; 95% confidence interval [CI], 2.120–5.500; p < 0.001), TVR (HR, 2.801; 95% CI, 1.890–4.151; p < 0.001), non-TVR (HR, 2.180; 95% CI, 1.413–3.364; p < 0.001) and MACE (HR, 2.383; 95% CI, 1.659–3.423, p < 0.001) were significantly higher in the RAF group. However, there were no significant differences observed in the incidence of CD, non-fatal MI, or ST between the two groups. Conclusions In older patients who underwent PCI with DES, RAF was associated with higher incidences of revascularization and MACE, despite of similar incidence of CD, non-fatal MI, or ST between the RAF and CF groups. These findings suggest that the implementation of the RAF strategy may not be necessary for older patients following PCI with DESs.