Patients with high-risk acute coronary syndromes have been shown to benefit from a strategy of early invasive catheterisation, and this is reflected in the US and European guidelines. However, the recently reported long-term follow-up from the Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) trial shows that even patients with elevated troponin may not benefit substantially from an early invasive strategy, compared with a “selective invasive” strategy, in the context of optimum medical therapy.1 Selected trials have suggested benefits from very early routine catheterisation,2 ,3 particularly among high-risk patients,3 although it remains unclear whether immediate catheterisation and revascularisation has measurable benefits compared with the more convenient approach …