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A growing body of clinical and experimental literature supports a strong association between emotional stress and adverse outcomes from CVD. Effects of emotional stress on coronary blood flow and cardiac arrhythmias provide only a partial explanation. A direct impact of emotional stress on myocardial function has recently received attention as a result of reports of patients presenting with new onset of unexplained reversible heart failure following episodes of emotional stress. Potential mechanisms responsible for myocardial dysfunction following emotional stress remain to be elucidated. This review will explore potential pathophysiologic mechanisms linking emotional stress to adverse cardiovascular outcomes beginning with primary and secondary risk factors and leading to direct effects of emotional stress on reversible myocardial dysfunction.