27Familial hypertrophic cardiomyopathy (HCM), a leading cause of sudden cardiac death, 28 is primarily caused by mutations in sarcomeric proteins. The pathogenesis of HCM is 29 complex, with functional changes that span scales from molecules to tissues. This makes 30 it challenging to deconvolve the biophysical molecular defect that drives the disease 31 pathogenesis from downstream changes in cellular function. Here, we examined a HCM 32 mutation in troponin T, R92Q. We demonstrate that the primary molecular insult driving 33 the disease pathogenesis is mutation-induced alterations in tropomyosin positioning, 34 which causes increased molecular and cellular force generation during calcium-based 35 activation. We demonstrate computationally that these increases in force are direct 36 consequences of the initial molecular insult. This altered cellular contractility causes 37 downstream alterations in gene expression, calcium handling, and electrophysiology. 38Taken together, our results demonstrate that molecularly driven changes in mechanical 39 tension drive the early disease pathogenesis, leading to activation of adaptive 40 mechanobiological signaling pathways. 41 (8). These studies have resulted in conflicting conclusions about the effects of the 65 mutation, at least in part due to phenotypic differences between species. For example, 66 the widely studied transgenic mouse model of R92Q (8) recapitulates some, but not all, 67 aspects of the disease phenotypes seen in humans. Elegant experiments by the Tardiff 68 lab have shown that the disease presentation in mice depends on the myosin heavy chain 69 isoform expressed, with different phenotypes seen when using the faster (MYH6) isoform 70 found in mouse ventricles or the slower (MYH7) isoform found in human ventricles (9). 71These studies highlight the need to study the mutation in humanized systems. 72Troponin T is part of the troponin complex, which, together with tropomyosin, 73 regulates the calcium-dependent interactions between myosin and the thin filament that 74 drive muscle contraction. Three models have been put forward to describe the initial 75 molecular insult that drives the disease pathogenesis of R92Q (Fig. 1B). 1) R92Q could 76 affect the cycling kinetics of myosins that are bound to the thin filament (9). In this model, 77one would expect to observe a change in the amount of time that myosin remains bound 78 to the thin filament during crossbridge cycling in the mutant. 2) R92Q could increase the 79 calcium affinity of the troponin complex, leading to altered calcium buffering by 80 myofilaments that directly disrupts calcium homeostasis (10-12). In this model, one would 81 expect to observe an increased binding affinity for calcium in the troponin complex 82 containing R92Q. 3) R92Q could alter the distribution of positions assumed by 83 tropomyosin along the thin filament, leading to changes in the fraction of bound myosin 84 crossbridges (13). In this model, one would expect to see changes in the equilibrium 85 constants that define the p...