Abstract:The endoplasmic reticulum (ER) is a multifunctional intracellular organelle supporting many processes required by virtually every mammalian cell, including cardiomyocytes. It performs diverse functions, including protein synthesis, translocation across the membrane, integration into the membrane, folding, posttranslational modification including N-linked glycosylation, and synthesis of phospholipids and steroids on the cytoplasmic side of the ER membrane, and regulation of Ca 2؉ homeostasis. Perturbation of ER-associated functions results in ER stress via the activation of complex cytoplasmic and nuclear signaling pathways, collectively termed the unfolded protein response (UPR) (also known as misfolded protein response), leading to upregulation of expression of ER resident chaperones, inhibition of protein synthesis and activation of protein degradation. The UPR has been associated with numerous human pathologies, and it may play an important role in the pathophysiology of the heart. ER stress responses, ER Ca 2؉ buffering, and protein and lipid turnover impact many cardiac functions, including energy metabolism, cardiogenesis, ischemic/reperfusion, cardiomyopathies, and heart failure. ER proteins and ER stress-associated pathways may play a role in the development of novel UPR-targeted therapies for cardiovascular diseases. (Circ Res. 2010;107:1185-1197.) Key Words: endoplasmic reticulum stress Ⅲ misfolded protein response Ⅲ autophagy Ⅲ endoplasmic reticulum-associated degradation Ⅲ cardiac disease T he endoplasmic reticulum (ER) is a centrally located, multifunctional, and multiprocess intracellular organelle supporting many mechanisms required by virtually every mammalian cell, including cardiomyocytes. The membrane performs a remarkable number of diverse functions, including protein synthesis, translocation across the membrane, integration into the membrane, folding, posttranslational modification including N-linked glycosylation, and synthesis of phospholipids and steroids on the cytoplasmic side of the ER membrane, and regulation of Ca 2ϩ homeostasis. 1 Development and maintenance of optimally functioning ER membrane is essential for virtually all cellular activities, from intracellular signaling to control of transcriptional pathways; ion fluxes to control of energy metabolism; protein synthesis to multisubunit assembly; and lipid synthesis to transcriptional regulation of steroid metabolism. One of the major advantages of the centrally located ER network for the cell is the ability to control the composition and the dynamics of the ER luminal environment in an extracellular environmentindependent way. Furthermore, the ER is not an isolated organelle because it has developed sophisticated mechanisms of communication with many other cellular compartments,