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The cardiac extracellular matrix, far from being merely a static support structure for the heart, is now recognized to play central roles in cardiac development, morphology, and cell signaling. Recent studies have better shaped our understanding of the tremendous complexity of this active and dynamic network. By activating intracellular signal cascades, the matrix transduces myocardial physical forces into responses by myocytes and fibroblasts, affecting their function and behavior. In turn, cardiac fibroblasts and myocytes play active roles in remodeling the matrix. Coupled with the ability of the matrix to act as a dynamic reservoir for growth factors and cytokines, this interplay between the support structure and embedded cells has the potential to exert dramatic effects on cardiac structure and function. One of the clearest examples of this occurs when cell-matrix interactions are altered inappropriately, contributing to pathological fibrosis and heart failure. This review will examine some of the recent concepts that have emerged regarding exactly how the cardiac matrix mediates these effects, how our collective vision of the matrix has changed as a result, and the current state of attempts to pharmacologically treat fibrosis. [ABSTRACT FROM AUTHOR]