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Abstract: Background: We compared the early diagnostic and prognostic performance of a highly sensitive cardiac troponin I (cTnI) assay with heart-type fatty acid binding protein (H-FABP), in the early hours of acute coronary syndrome. Methods: Serum samples of 293 patients were studied using the Abbott Architect cTnI assay and the H-FABP assay. Special attention was paid to the diagnostic and prognostic value of admission blood samples taken <24 h after symptom onset. The prognostic endpoint was total mortality and reinfarction at 6 months. Results: To detect forthcoming myocardial injury, admission samples gave receiver operating curve (ROC) areas (AUC) of 0.908 for cTnI and 0.855 for H-FABP (p =0.068) when the delay from symptom onset was <6 h (60.4% of all patients). When the delay was 6–24 h, the corresponding AUC values were 0.995 for cTnI and 0.849 for H-FABP (p =0.002). In multivariate analysis cTnI but not H-FABP predicted adverse events in all 293 patients (RR 3.02, 95% CI 1.62–5.63) and in those with delays <6 h (RR 2.92, 95% CI 1.47–5.81). Conclusion: In the era of highly sensitive cTnI assays, H-FABP appears to give no additional information even in patients who present within the first 6 h after acute MI. [Copyright &y& Elsevier]