Csx/Nkx2-5, which is essential for cardiac development of the embryo, is abundantly expressed in the adult heart. We here examined the role of Csx/Nkx2-5 in the adult heart using two kinds of transgenic mice. Transgenic mice that overexpress a dominant negative mutant of Csx/Nkx2-5 (DN-TG mice) showed degeneration of cardiac myocytes and impairment of cardiac function. Doxorubicin induced more marked cardiac dysfunction in DN-TG mice and less in transgenic mice that overexpress wild type Csx/Nkx2-5 (WT-TG mice) compared with non-transgenic mice. Doxorubicin induced cardiomyocyte apoptosis, and the number of apoptotic cardiomyocytes was high in the order of DN-TG mice, non-transgenic mice, and WT-TG mice. Overexpression of the dominant negative mutant of Csx/Nkx2-5 induced apoptosis in cultured cardiomyocytes, while expression of wild type Csx/Nkx2-5 protected cardiomyocytes from doxorubicin-induced apoptotic death. These results suggest that Csx/Nkx2-5 plays a critical role in maintaining highly differentiated cardiac phenotype and in protecting the heart from stresses including doxorubicin.The cardiac homeobox gene Csx/Nkx2-5 starts to be expressed at embryonic day 7.5 in the heart primordia of mice (1, 2), and targeted disruption of murine Csx/Nkx2-5 results in embryonic lethality (3). Many mutations in human Csx/Nkx2-5 have been reported to cause a variety of congenital heart diseases and atrioventricular conduction delay (4, 5). These observations indicate that Csx/Nkx2-5 plays a critical role in cardiac morphogenesis and contributes to diverse cardiac developmental pathways at the embryonic stage.Knockout experiments have suggested that many genes such as Hand1, myocyte enhancer factor-2, atrial natriuretic peptide (ANP), 1 brain natriuretic peptide (BNP), cardiac ␣-actin, cardiac ankyrin repeat protein (CARP), N-myc, and MSX2 are genetically located downstream of Csx/Nkx2-5 at the embryonic stage (2, 6 -8). Although Csx/Nkx2-5 continues to be expressed in the adult heart (1, 2), the function of Csx/Nkx2-5 in the later stage of development is unknown because of embryonic lethality of null mutant mice (3, 8). In our recently generated transgenic mice that overexpress human Csx/Nkx2-5 (WT-TG mice), mRNA levels of many cardiac genes such as ANP, BNP, CARP, and sarcoplasmic reticulum calcium ATPase 2 (SERCA2) genes were up-regulated (9). These results suggest that Csx/Nkx2-5 regulates expression of cardiac-specific genes also in the adult heart. However, because there was no difference in phenotype between WT-TG and non-transgenic (non-TG) mice (9), the significance of these gene up-regulations remains unknown. Csx/Nkx2-5 itself is also differentially regulated by different stimuli. In response to hypertrophic stimuli such as isoproterenol, phenylephrine, and pressure overload, Csx/Nkx2-5 is upregulated (10, 11), whereas it is down-regulated by treatment with doxorubicin (DOX) (12). These results suggest that Csx/ Nkx2-5 has certain roles in the adult heart. In this study, we generated transgenic mice that over...