The diagnosis of cardiac ischemia remains a challenge in contemporary emergency medicine. A blood-borne biomarker is an attractive alternative to cardiac imaging or stress testing as it would be cheaper and logistically faster to obtain. A number of candidate biomarkers have been proposed for the detection of cardiac ischemia; however, only Ischemia Modified Albumin (IMA) has been released for clinical use. IMA is a good discriminator between ischemic and non-ischemic patients. Changes in IMA concentration have shown to occur during coronary angioplasty-induced ischemia. Clinical studies indicate that IMA appears to offer on admission an early test which can be combined with electrocardiographic findings and cardiac troponin measurements for the early exclusion of acute coronary syndrome. IMA is an independent predictor of short and long term adverse outcomes in patients with acute chest pain. However, this test is relatively new and uncertainties remain. Elevations of IMA occur in conditions other than chest pain, thus questioning its specificity. The mechanism of IMA formation and the precise entity being measured are not fully known. Nevertheless, IMA measurement remains the only current clinical biomarker which may be used for the diagnosis of patients suspected of cardiac ischemia.