Abstract Background: We sought to determine the diagnostic accuracy of the cardiac troponin I (cTnI) VITROS® Troponin I-ES assay for early detection of acute myocardial infarction (AMI) and for risk prediction of adverse events in patients with symptoms of acute coronary syndrome (ACS). Methods: cTnI was measured on admission and approximately 6 h postadmission in 381 patients. The 99th percentile cTnI concentration (0.034 μg/L) and change [delta (δ)] between admission and follow-up concentrations were evaluated in diagnostic sensitivity and specificity calculations. Risk of cardiac event or death within 60 days was evaluated by Cox proportional hazards regression. Results: AMI occurred in 52 patients. Diagnostic sensitivities (95% CI) of admission and follow-up cTnIs for AMI were 69% (55%–81%) and 94% (84%–99%), respectively. The corresponding specificities (95% CI) were 78% (73%–82%) and 81% (77%–85%), and ROC curve areas were 0.82 vs 0.96 (P < 0.001). Deltas between admission and follow-up cTnI >30% had a sensitivity of 75% (95% CI 61%–86%) and a specificity of 91% (95% CI 87%–94%). During follow-up, 1 cardiac death, 2 noncardiac deaths, 52 AMIs, 6 coronary artery bypass grafts, and 43 percutanous coronary interventions occurred in 62 patients. A δ cTnI >30%, when added to either initial cTnI >0.034 μg/L or follow-up cTnI >0.034 μg/L, improved risk stratification for cardiac event or death (P < 0.001). Conclusions: Admission cTnI measured by the VITROS ES assay is a sensitive biomarker for detection of AMI. Utilizing >30% cTnI δ in addition to either the baseline or follow-up concentration improved both specificity and risk assessment in patients presenting with symptoms of ACS.