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This editorial refers to ‘Optimal timing of invasive angiography in stable non-ST-elevation myocardial infarction: the Leipzig Immediate versus early and late PercutaneouS coronary Intervention triAl in NSTEMI (LIPSIA-NSTEMI Trial)’†, by H. Thiele et al. , on page 2035 Non- ST-elevation acute coronary syndrome (NSTE-ACS) represents the majority of ACS. Despite the fact that we pay most attention to ST-elevation-ACS, NSTE-ACS is where logistically the action is, as these patients account for ∼3 out of 4 hospital ACS discharges.1 Recent studies have helped to clarify that a strategy of routine catheterization is superior to a conservative strategy of catheterization only if the patient develops spontaneous or stress-induced ischaemia. Routine angiography and revascularization after NSTE-ACS reduces mortality by 25%, myocardial infarction by 18%, and re-hospitalization for unstable angina by 31% at mid-term follow-up.2 However, it is still controversial, for initially stabilized patients, whether the catheterization and percutaneous coronary intervention (PCI) need to be done early (i.e. within 24 h) or whether they could be delayed ≥1 day while the patient receives medical therapy and logistic attention. Thus, should we open our laboratories 24 h a day, every day, to catheterize NSTE-ACS patients early, even within the first few hours of hospital admission, analogous to the standard of primary PCI?Five trials (ISAR-COOL,3 ELISA,4 ABOARD,5 TIMACS,6 and OPTIMA7) and a meta-analysis8 have compared ‘early’vs. ‘delayed’ intervention in stable NSTE-ACS before the LIPSIA-NSTEMI9 trial and form the basis of the recently updated recommendations in both American and European guidelines.10,11 Unstable patients with very high risk, i.e. those with refractory angina, heart failure, life-threatening arrhythmias, or haemodynamic instability, have not been included in these trials and should be subject to an immediate (<2 h) invasive strategy similar to the case for ST-elevation ACS.10 …

Catheterization laboratories open 24 hours a day, every day: does stable non-ST-elevation acute coronary syndrome need the offer?