The early diagnosis of acute coronary syndrome remains problematic, despite recent improvements. Traditionally, the diagnosis of acute cardiac ischaemia relies on the combination of chest pain, electrocardiographic changes and elevation of serum markers. Troponins are currently the "gold standard" test for the detection of myocardial necrosis, but they are unsuitable for early diagnosis, as nearly 50% of patients may present to the emergency department with non-diagnostic concentrations. Ischaemia modified albumin increases within minutes after the onset of ischaemia, remains elevated for 6 to 12h, and returns to normal within 24h. Thus, it may be a valuable aid for the clinician enabling early detection of ischaemia before the development of myocardial necrosis. Its high sensitivity comes at the expense of a lower specificity because its increase may be due to ischaemia of other tissues such as gastrointestinal tissues or skeletal muscles tissues. This paper has focuses on the cardiology aspect of this biomarker, underlying its potential value in the emergency department.