Aldehyde dehydrogenase (ALDH) 2 is a mitochondrial isozyme of the heart involved in the metabolism of toxic aldehydes produced from oxidative stress. A decrease in ALDH2 levels and activity was reported in the hearts of experimental hyperglycemia along with an increase in 4-hydroxy-2-nonenal (4HNE). 4HNE is produced in the mitochondria upon lipid peroxidation and known to form adduct with mitochondrial proteins. We hypothesize that reduced ALDH2 activity impairs mitochondrial respiration due to 4HNE adducts formation, ultimately resulting in cardiac damage in hyperglycemia. A single dose (65 mg/kg; i.p.) of streptozotocin in rats resulted in hyperglycemia with a blood glucose level of 443 ± 9 mg/dl versus 121 ± 7 mg/dl in control animals, p<0.0001. N=7-11 in both groups. After 6 months of hyperglycemia, heart function was recorded and the rats were sacrificed. Increases in cardiomyocyte cross sectional area (446 ± 32 μm2Vs 221 ± 10 μm2; p<0.0001) indicated cardiac hypertrophy in diabetic rats. Both diastolic and systolic dysfunctions were recorded with diabetic rats compared to controls. For instance, % fractional shortening was lower in diabetic group versus control; (p<0.0001). Most importantly, myocardial ALDH2 activity and levels were reduced and immunostaining for 4HNE protein adducts was increased in diabetic hearts compared to controls. The mitochondrial oxygen consumption rate (OCR), an index of mitochondrial respiration, was decreased in mitochondria isolated from diabetic hearts compared to controls (p<0.0001). To check the direct effect of 4HNE and ALDH2 inhibition, we treated H9C2 cardiomyocytes with 4HNE and disufiram, an ALDH inhibitor, respectively, which reduced mitochondrial respiration (p<0.0001) and cell viability (p<0.0001) along with reduced ALDH2 activity and increased 4HNE adducts formation. We conclude that chronic hyperglycemia-induced 4HNE accumulation due to low ALDH2 activity in the heart leads to defective mitochondrial respiration and cardiac damage and dysfunction.