The hospital admission of patients with acute coronary syndromes without ST-segment elevation is increasing in the real world. The aim of the BLITZ-2 study, carried out in May 2003, was to investigate the epidemiology and management of patients admitted with a diagnosis of non-ST-elevation myocardial infarction. The study enrolled 1888 patients with a mean age of 68 years. Among the involved hospitals a cath-lab was available in 67.7% in northern Italy vs 37 and 39.8% in central and southern Italy, respectively. Only 44 and 55% of patients underwent coronary angiography during the first hospital admission in central and southern Italy, respectively, against 68% of patients in northern Italy. The type of strategy was more influenced by the availability of a cath-lab than by the TIMI risk score. A conservative strategy was applied in 45% of patients (26% in hospitals with a cath-lab) whereas an invasive approach was used in 55% of patients (74% in hospitals with a cath-lab). There was no difference in the TIMI risk score between the groups. Age was predictor of coronary angiography: 71% in patients < 55 years, 63% in patients 55-74 years, and 44% in patients > or = 75 years. The in-hospital mortality was 1.2% (1% in northern Italy, 1.4% in central Italy, 1.4% in southern Italy) and was higher in high-risk patients (1.5% with TIMI risk score > 5) and in older patients (3% in those > or = 75 years). The 1-month mortality and reinfarction was 2.4 and 3.6%, respectively. The total in-hospital stay was 8.8 days (coronary care unit stay 3.9 days). The contemporary management of Italian patients with acute coronary syndrome turned out to be influenced by resource availability, and elderly patients and subjects at higher risk are undertreated.