The prognosis for patients with non-ST elevation acute coronary syndromes (ACS) is not benign. Ongoing ischaemia is only one determinant of risk. The presence of ST-segment depression or elevated level of troponins is known to identify a group of patients at high risk of further events (death, MI, re-admission with ACS).The key management issue, however, is regarding which of these patients require early (i.e. in-hospital) revascularisation. Based upon current evidence from studies including FRISC II, TIMI-18, and the recent re-analysis of TIMI-III, our current strategy is to offer invasive investigation and revascularisation to all patients identified as ‘high risk’.