Ischemia modified albumin (IMA), as measured using the albumin cobalt binding test, is currently the most promising biomarker for early detection of ischemia before the onset of irreversible cardiac injury. This paper reviews the information available on IMA, including its pathophysiology, analysis, clinical applications and future perspectives. The data provided was identified by a search of MEDLINE using the terms IMA, biomarkers and ischemia. IMA may be useful to cover the complete diagnostic window of patients presenting with acute coronary syndromes (ACS) in the Emergency Department, along with the electrocardiogram and cardiac troponins. Preliminary data regarding the significance of IMA in the prognosis of either ACS or following revascularization need further study.