The giant sarcomeric protein titin is a key determinant of myocardial passive stiffness and stress sensitive signaling. Titin stiffness is modulated by isoform variation, phosphorylation by protein kinases and possibly oxidative stress through disulfide bond formation. Titin has also emerged as an important human disease gene. Early studies in patients with dilated cardiomyopathy (DCM) revealed shifts toward more compliant isoforms, an adaptation that offsets increases in passive stiffness based in the extracellular matrix. Similar shifts are observed in heart failure with preserved ejection fraction (HFpEF). In contrast, hypophosphorylation of PKA/G sites contributes to a net increase in cardiomyocyte resting tension in HFpEF. More recently, titin mutations have been recognized as the most common etiology of inherited DCM. In addition, some DCM-causing mutations affect RBM20, a titin splice factor. Titin mutations are a rare cause of hypertrophic cardiomyopathy (HCM) and also underlie some cases of arrhythmogenic right ventricular dysplasia. Finally, mutations of genes encoding proteins that interact with and/or bind to titin are responsible for both DCM and HCM. Targeting titin as a therapeutic strategy is in its infancy, but could potentially involve manipulation of isoforms, post-translational modifications, and up-regulation of normal protein in patients with disease causing mutations.