OBJECTIVES To assess cost-effectiveness of high sensitivity troponin (hs-cTn) assays for the management of adults presenting with acute chest pain at the emergency department. METHODS An economic model was constructed to estimate lifetime costs and QALYs of five hs-cTn strategies (differing according to manufacturer, timing of the test, number of tests and cutoff point for a positive test result) compared to standard troponin (sTn) testing at presentation and at 10-12 hours, which was considered the reference standard. In the base case, it was assumed that sTn testing had perfect accuracy for diagnosing AMI and only patients with a positive test for sTn were at increased risk for adverse events and would benefit from immediate treatment. In a secondary analysis, a proportion of patients with a positive hs-cTn test and a negative sTn test were at increased risk for adverse events and would benefit from immediate treatment. RESULTS Base case: Strategies considered cost-effective depending upon ICER thresholds were Abbott ARCHITECT hs-cTnI 99th centile (thresholds <£6,597), Beckman Coulter hs-cTnI 99th centile (thresholds £6,597 - £30,042), Abbott ARCHITECT hs-cTnI optimal strategy (thresholds £30,042 - £103,194), and the sTn test (thresholds >£103,194). Secondary analysis: Strategies considered cost-effective were Abbott ARCHITECT hs-cTnI 99th centile (<£12,217), Roche Elecsys hs-cTnT 99th centile (£12,217 - £14,992) and Abbott ARCHITECT hs-cTnI optimal strategy (>£14,992). STn was dominated. Sensitivity/subgroup analyses: Main drivers are: the difference in outcomes between treated and untreated patients, and treatment costs for patients testing false-positive. Hs-cTn testing is more cost-effective in younger age, pre-existing coronary artery disease, and symptom onset <3hrs ago. No testing is only cost-effective when pre-test prevalence is 1%. CONCLUSIONS There is no strong evidence to prefer one hs-cTn testing strategy over another. Results do indicate that hs-cTn testing in general may be cost-effective compared to sTn testing, especially in the secondary analysis.