This review addresses the potential use of the intracellular ryanodine receptor (RyR) Ca2+ release channel as a therapeutic target in heart disease. Heart disease encompasses a wide range of conditions with the major contributors to mortality and morbidity being ischaemic heart disease and heart failure (HF). In addition there are many rare, but devastating conditions, some of which are either genetically linked to the RyR and its regulatory proteins or involve drug-induced modification of the proteins. The defects in Ca2+ signalling vary with the nature of the heart disease and the stage in its progress and therefore specific corrections require different modifications of Ca2+ signalling. Compounds that activate the RyR are potential inotropic agents to increase the Ca2+ transient and strength of contraction. Compounds that reduce RyR activity are potentially useful in conditions where excess RyR activity initiates arrhythmias, or depletes the Ca2+ store, as in end stage HF. It has recently been discovered that the cardio-protective action of the drug JTV519 can be attributed partly to its ability to stabilise the interaction between the RyR and the 12.6 kDa binding protein for the commonly used immunosuppressive drug FK506 (FKBP12.6, known as tacrolimus). This has established the credibility of the RyR as a therapeutic target. We explore the possibility that mutations causing the rare RyR-linked arrhythmias will open the door to identification of novel RyR-based therapeutic agents. The use of regulatory binding sites within the RyR complex or on its associated proteins as templates for drug design is discussed.