Cardiovascular disease is the most common cause of death in patients with renal failure. Patients with renal failure are at greater risk of atypical presentations of myocardial ischaemia. Traditional markers of myocardial damage are often increased in renal failure in the absence of clinically suspect myocardial ischaemia. The cardiac troponins are specific markers of myocardial injury. Large-scale trials, excluding patients with renal disease, have shown the importance of the cardiac troponins in predicting adverse outcome and in guiding both therapy and intervention in acute coronary syndromes. Cardiac Troponin T and cardiac Troponin I are increased in patients with renal failure and this is likely to represent multifactorial pathology including cardiac dysfunction, left ventricular hypertrophy and cardiac microinfarctions. Increases in serum troponin from baseline, in patients with renal disease with acute coronary syndromes, may represent a poor prognosis. Small studies of patients with renal failure have suggested that elevation of the cardiac troponins is associated with an increased risk of cardiac death.