Calcium lons play a major role in controlling both the electrical and mechanical activity of the heart. These important regulatory functions are affected when calcium moves across cellular membranes, including the sarcolemma and sarcoplasmic reticulum. These membranes are composed of a hydrophobic lipid bilayer, which constitutes a barrier to the flux of ions in which are embedded a number of intrinsic membrane proteins. Some of the latter are involved in the movement of calcium between different regions of the myocardial cell. The “downhill” movement of calcium from regions of high Ca ++ activity in the extracellular space and sarcoplasmic reticulum into the cytosol, where Ca ++ concentration is much lower, is mediated by “channels” that are probably lined by hydrophilic regions of the intrinsic membrane proteins. The sarcolemmal calcium channels, which carry the slow inward current that is responsible for the plateau phase of the cardiac action potential, is regulated by a voltage-sensitive gating mechanism that controls the access of ions to the channel. The calcium permeability of the sarcoplasmic reticulum, which regulates the calcium release into the cytosol that initiates cardiac systole, may be regulated by the calcium pump adenosine triphosphatase (ATPase) protein, also responsible for the active transport of calcium back into the sarcoplasmic reticulum during diastole. Drugs that affect the flux of ions through membrane “channels” can act by inducing the phosphorylation of membrane proteins, for example, phospholamban in the cardiac sarcoplasmic reticulum, which is phosphorylated in response to elevated cyclic adenosine monophosphate (cAMP) induced by β-receptor agonists. Other agents may bind directly to channel proteins, for example, tetrodotoxin, which binds specifically to the fast channel. It appears likely that many drugs, including antiarrhythmic agents and possibly calcium channel blockers, may modify ion fluxes through membrane channels by an interaction with functionally important membrane lipids surrounding the hydrophobic regions of the “channel” proteins. Abnormal calcium movements may contribute to the depression of myocardial contractility seen in the failing heart. These alterations may be produced by abnormalities in both the “channel” proteins and the membrane lipids in which the channels are embedded. It is not clear whether these abnormalities, and the resulting depression of contractility in the failing heart, represent a “defect” that shortens survival in these patients or whether the accompanying reduction in energy demand may be at least in part compensatory.