Abstract-Patients with heart failure experience a number of changes in the electrical function of the heart that predispose to potentially lethal cardiac arrhythmias. Action potential prolongation, the result of functional downregulation of K currents, and aberrant Ca 2ϩ handling is a recurrent theme. Significant alterations in conduction and activation of a number of initially adaptive but ultimately maladaptive signaling cascades contribute to the generation of a highly arrhythmogenic substrate. We review the changes in active and passive membrane properties, neurohumoral signaling, and genetic determinants that predispose to sudden arrhythmic death in patients with heart failure and highlight the critical unanswered questions that are ripe for future investigation. Key Words: arrhythmia Ⅲ Ca 2ϩ handling Ⅲ cardiac electrophysiology Ⅲ heart failure Ⅲ ionic remodeling N early 5 million Americans experience heart failure (HF) and Ͼ250 000 die annually. The incidence and prevalence has continued to increase with the aging of the US population. 1 Despite remarkable improvements in medical therapy, the prognosis of patients with myocardial failure remains poor, with almost 20% of patients dying within 1 year of initial diagnosis and Ͼ80% 8-year mortality. Of the deaths in patients with HF, up to 50% are sudden and unexpected; indeed, patients with HF have 6-to 9-times the rate of sudden cardiac death (SCD) of the general population. 1 What causes SCD in patients with HF? It is safe to say that in any individual patient, the mechanism of SCD is uncertain. The uncertainty begins with the definition of sudden death, which describes a sequence of events, not a mechanism. The presumption is that SCD is produced by a lethal cardiac arrhythmia, most often ventricular tachycardia or fibrillation.Bradyarrhythmias and pulseless electrical activity occur less frequently, and generally in hearts with more advanced structural disease. Some data suggest that bradyarrhythmias and pulseless electrical activity may account for an increasing percentage of SCDs, because the frequency of ventricular tachycardia and fibrillation (VT/VF) may be decreasing. 2 The World Health Organization definition of sudden death certainly leaves open the possibility that death may result from a precipitous decline in mechanical function of the heart, such as pulseless electrical activity. Even sudden witnessed death may be produced by a sudden mechanical or vascular catastrophe (pulmonary embolus, cardiac, or vascular rupture) rather than a malignant cardiac rhythm abnormality.SCD most likely results from a cascade of "upstream" events that create an electrically unstable heart that most often is manifested by a ventricular tachyarrhythmia. Interestingly, it is the nonantiarrhythmic drugs, ie, those without What is certain about SCD in the setting of HF in particular is that there are a number of structural and functional changes in the heart and genetic predisposition that may contribute to an increased risk of dying suddenly. This review considers so...