Troponin is the main marker for the diagnosis of acute coronary syndrome (ACS). Increased use of the troponin assay in other settings shows many clinical situations with elevated levels. These elevations can be seen both inside and outside the emergency department. A difficult group of patients present with typical chest pain to the emergency department and have elevated troponin levels that are not caused by ACS. In this group belong the takotsubo cardiomyo-pathy, aortic dissection and inflammatory cardiac conditions such as pericarditis, myocarditis and endocarditis. Patients that present with shortness of breath frequently have elevation of troponin levels. Pulmonary embolism is well recognised as a cause of elevation of troponin as are acute respiratory distress syndrome and pulmonary hypertension. However, tropo-nin elevation has been described in patients with exacerbation of chronic obstructive pulmonary disease. Other causes are heart failure, critical illness, sepsis and stroke. End stage renal disease patients frequently have elevated troponin but now we see troponin elevations also with exercise and rapid heart rate. Therefore, one has to be very careful when assessing patients with troponin levels and take into account history, examination and coexisting illness. With new high sensitivity troponin assays we can expect increased percentages of ill patients to have troponin elevations.