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Aims: To examine trends in the use of diagnostic coronary angiography according to distance from home to the nearest invasive heart centre following implementation of fast-track protocols and extensive pre-hospital triaging of acute coronary syndrome patients.Methods and results: We performed a register-based cohort study of all patients admitted to Danish hospitals with incident acute coronary syndrome in 2005–2011. Diagnostic coronary angiography within 60 days of admission was investigated according to distance tertiles (DTs) calculated as range from each patient’s home to the nearest invasive heart centre (short DT: <22 km, medium DT: 22–65 km, long DT: >65 km). Cox proportional hazards models were applied. Among the 52,409 patients included, diagnostic coronary angiography was increasingly used during 2005–2011 (short DT: 76% to 81%; medium DT: 74% to 81%; long DT: 69% to 78%; all p-values for trend <0.001). Using the short DT as reference the adjusted hazard ratios for medium DT were 0.87 (0.84–0.89) for 2005–2007, 0.94 (0.90–0.98) for 2008–2009 and 0.94 (0.90–0.98) for 2010–2011. Corresponding figures for long DT were 0.74 (0.72–0.76) for 2005–2007, 0.87 (0.83–0.90) for 2008–2009 and 0.94 (0.90–0.98) for 2010–2011. Length of hospital stay, time to coronary angiography, and 60-day mortality decreased in all DT.Conclusions: This nationwide study found significant increases in diagnostic coronary angiography use over time in incident acute coronary syndrome patients with a relatively larger increase in patients residing farthest from an invasive heart centre. Additionally, selected quality of care measures improved in the entire cohort, suggesting a benefit of national clinical protocols.