In this brief article, we summarize recent reports about endogenous ouabain (EO), a cardiotonic steroid hormone. This includes analysis of mammalian EO, the discovery of EO isomers, regulation of intracellular signaling by EO, and the roles of EO in hypertension, pregnancy, and heart and kidney diseases. Novel ouabain-resistant mice that elucidate the key roles of α2 Na+ pumps and their cardiotonic steroid-binding site are also discussed. EO was first identified in human plasma 25 years ago.1,2 Despite confirmation in humans and other mammals with mass spectrometry (MS; Figure; Figures S1–S6 in the online-only Data Supplement), nuclear magnetic resonance, and combined liquid chromatography (LC)–immunology methods,3–6 human EO has remained controversial.7 New analytic studies and related findings should allay skepticism. For example, employment of multistage MS (MS–MS and MS–MS–MS) to examine the effects of pregnancy and of central angiotensin (Ang) II infusion on EO in rat plasma led to the discovery of 2 novel EO isomers.8,9 Isomer 1 has MS–MS and MS–MS–MS product ion spectra indistinguishable from those of EO, but is slightly more polar than EO; it binds to the antibody used in our radioimmunoassay. Isomer 2 is slightly less polar than EO, has a distinct MS–MS–MS spectrum, and cross reacts weakly in our radioimmunoassay. The primary structural difference(s) between EO and these isomers may involve the steroid nucleus. Importantly, neither isomer was previously described or is detectable in commercial (plant) ouabain.8,9 Figure. Endogenous ouabain determined by liquid chromatography (LC)–mass spectrometry (MS)–MS in plasma from patients with cardiomyopathy. A , Capillary LC–MS–MS product ion chromatogram for a plasma extract from a patient with cardiomyopathy. The ion current peaks represent positively charged molecular product ions with an M+Li+/z ratio equivalent to the lithiated aglycone of ouabagenin …