Cardiovascular disease remains a major cause of morbidity and mortality in modern societies. While contemporary treatment modalities are making steady inroads to reduce this disease burden there remains a pressing need to vigorously explore novel therapeutic strategies. Rapid advances in our understanding of molecular pathology and the evolution of increasingly efficient gene transfer technology offer the imminent prospect of gene-based approaches to, at least, a subset of cardiovascular pathophysiologies. Initially envisaged as a treatment strategy for inherited monogenic disorders, it is now apparent that gene therapy has broader potential that encompasses acquired polygenic diseases, including many that affect the cardiovascular system. Extensive in vitro and animal studies are providing an increasingly sound scientific basis for cautious human evaluation. This review focuses on gene therapy of diseases primarily afflicting the heart, and provides an overview of gene and vector delivery systems with particular emphasis on systems suited to individual cardiac conditions. The pathophysiology underlying these conditions and molecular targets for therapeutic intervention are also reviewed.