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Coronavirus disease 2019 (COVID-19) has presented substantial challenges to patient care and impacted healthcare delivery, including cardiac electrophysiology practice throughout the globe. Based upon the undetermined course and regional variability of the pandemic, there is uncertainty as to how and when to resume and deliver electrophysiology services for patients with arrhythmia. This joint document from representatives of the Heart Rhythm Society, American Heart Association, and American College of Cardiology seeks to provide guidance for clinicians and institutions reestablishing safe electrophysiological care. To achieve this aim, we address regional and local COVID-19 disease status, the role of viral screening and serological testing, return-to-work considerations for exposed or infected health care workers, risk stratification and management strategies based on COVID-19 disease burden, institutional preparedness for resumption of elective procedures, patient preparation and communication, prioritization of procedures, and development of outpatient and periprocedural care pathways.

The interrelationships between atrial fibrillation (AF) and heart failure (HF) are complex and poorly understood, yet the number of patients with AF and HF continues to increase worldwide. Thus, there is a need for initiatives that prioritize research on the intersection between AF and HF. This article summarizes the proceedings of a virtual workshop convened by the US National Heart, Lung, and Blood Institute to identify important research opportunities in AF and HF. Key knowledge gaps were reviewed and research priorities were proposed for characterizing the pathophysiological overlap and deleterious interactions between AF and HF; preventing HF in people with AF; preventing AF in individuals with HF; and addressing symptom burden and health status outcomes in AF and HF. These research priorities will hopefully help inform, encourage, and stimulate innovative, cost-efficient, and transformative studies to enhance the outcomes of patients with AF and HF.

IMPORTANCE: Ventricular tachycardia (VT) is associated with high mortality in patients with cardiac sarcoidosis (CS), and medical management of CS-associated VT is limited by high failure rates. The role of catheter ablation has been investigated in small, single-center studies. OBJECTIVE: To investigate outcomes associated with VT ablation in patients with CS. DESIGN, SETTING, AND PARTICIPANTS: This cohort study from the Cardiac Sarcoidosis Consortium registry (2003-2019) included 16 tertiary referral centers in the US, Europe, and Asia. A total of 158 consecutive patients with CS and VT were included (33% female; mean [SD] age, 52 [11] years; 53% with ejection fraction [EF]

The QT interval is an electrocardiographic measure representing the sum of ventricular depolarization (QRS duration) and repolarization (JT interval). Abnormalities of the QT interval are associated with potentially fatal ventricular arrhythmia. We conducted genome-wide multi-ancestry analyses in >250,000 individuals and identified 177, 156 and 121 independent loci for QT, JT and QRS, respectively, including a male-specific X-chromosome locus. Using gene-based rare-variant methods, we identified associations with Mendelian disease genes. Enrichments were observed in established pathways for QT and JT, with new genes indicated in insulin-receptor signalling and cardiac energy metabolism. In contrast, connective tissue components and processes for cell growth and extracellular matrix interactions were significantly enriched for QRS. We demonstrate polygenic risk score associations with atrial fibrillation, conduction disease and sudden cardiac death. Prioritization of druggable genes highlighted potential therapeutic targets for arrhythmia. Together, these results substantially advance our understanding of the genetic architecture of ventricular depolarization and repolarization.

With the advent of novel cancer therapeutics and improved screening, more patients are surviving a cancer diagnosis or living longer with advanced disease. Many of these treatments have associated cardiovascular toxicities that can manifest in both an acute and a delayed fashion. Arrhythmias are an increasingly identified complication with unique management challenges in the cancer population. The purpose of this scientific statement is to summarize the current state of knowledge regarding arrhythmia identification and treatment in patients with cancer. Atrial tachyarrhythmias, particularly atrial fibrillation, are most common, but ventricular arrhythmias, including those related to treatment-induced QT prolongation, and bradyarrhythmias can also occur. Despite increased recognition, dedicated prospective studies evaluating true incidence are lacking. Moreover, few studies have addressed appropriate prevention and treatment strategies. As such, this scientific statement serves to mobilize the cardio-oncology, electrophysiology, and oncology communities to develop clinical and scientific collaborations that will improve the care of patients with cancer who have arrhythmias.

Glenn N. Levine, MD, FACC, FAHA, Chair Patrick T. O’Gara, MD, MACC, FAHA, Chair-Elect Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair [‡‡][1] Sana M. Al-Khatib, MD, MHS, FACC, FAHA Joshua A. Beckman, MD, MS, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD, PhD

BACKGROUND Athletes with an implantable cardioverter-defibrillator (ICD) may require unique optimal device-based tachycardia programming. OBJECTIVE The purpose of this study was to assess the association of tachycardia programming characteristics of ICDs with occurrence of shocks, transient loss-of-consciousness, and death among athletes. METHODS A subanalysis of a prospective, observational, international registry of 440 athletes with ICDs followed for a median of 44 months was performed. Programming characteristics were divided into groups for rate cutoff (very high, high, or low) and detection (long-detection interval [> nominal] or nominal). Endpoints included total, appropriate, and inappropriate shocks, transient loss-of-consciousness, and mortality. RESULTS In this cohort, 62% were programmed with high-rate cutoff and 30% with long detection. No athlete died of an arrhythmia (related or unrelated) to ICD shocks. Three patients had sustained ventricular tachycardia below programmed detection rate, presenting as palpations and/or dizziness. ICD shocks were received by 98 athletes (64 appropriate, 32 inappropriate); 2 patients received both. Programming a high-rate cutoff was associated with decreased risk of total (P = .01) and inappropriate (P = .04) shocks overall and during competition or practice. Programming long-detection intervals was associated with fewer total shocks. Single-vs dual-chamber devices and the number of zones were unrelated to risk of shock. Transient loss-of-consciousness, associated with 27 appropriate shocks, was not related to programming characteristics. CONCLUSION High-rate cutoff and long- detection duration programming of ICDs in athletes at risk for sudden death can reduce total and inappropriate ICD shocks without affecting survival or the incidence of transient loss-of-consciousness.

AIMS Chronic pain at the cardiovascular implantable electronic device (CIED) generator or lead insertion site that is not otherwise manageable carries a IIA indication for extraction. However, limited data exist evaluating causes of pain and outcomes of extraction in eliminating pain. A multi-centre retrospective observational study was conducted to evaluate outcomes of patients undergoing device extraction for treatment of chronic device pain. METHODS AND RESULTS Twenty-seven out of 2188 lead extraction candidates (1.3%) met the chronic pain IIA indication for extraction [50 ± 16 years; 14 (51%) women]. Onset, severity, triggers, and pain management were measured before and after extraction. Device type, procedure done (with/without reimplantation), and positive tissue cultures were noted. Pain was reported as constant (n = 14; 50%), intermittent (n = 13; 46%), and movement-triggered (n = 14; 50%). Average severity of pain was seven out of 10 (10 being the worst). Post-extraction, 18 (66%) received freedom from pain, including all patients with poorly formed pockets (n = 2) and subclinical infections (n = 2). Of the 18, 11 underwent reimplantation (61%) without recurrent pain. Nine still had pain (44 ± 17 years; seven women) after extraction. Eight of the nine underwent reimplantation, three on the contralateral chest wall and five ipsilaterally. Pain severity decreased (n = 5), increased (n = 1), or was unchanged (n = 3). CONCLUSION Chronic pain at the CIED generator site can present as chronic or movement-triggered pain, and can be due to subclinical infection or a poorly formed device pocket. Extraction relieved constant and intermittent pain in two-thirds of patients. Extraction appears less successful in eliminating pain in women who undergo subsequent reimplantation.

Cardiac sarcoidosis is a component of an often multiorgan granulomatous disease of still uncertain cause. It is being recognized with increasing frequency, mainly as the result of heightened awareness and new diagnostic tests, specifically cardiac magnetic resonance imaging and18F-fluorodeoxyglucose positron emission tomography scans. The purpose of this case-based review is to highlight the potentially life-saving importance of making the early diagnosis of cardiac sarcoidosis using these new tools and to provide a framework for the optimal care of patients with this disease. We will review disease mechanisms as currently understood, associated arrhythmias including conduction abnormalities, and atrial and ventricular tachyarrhythmias, guideline-directed diagnostic criteria, screening of patients with extracardiac sarcoidosis, and the use of pacemakers and defibrillators in this setting. Treatment options, including those related to heart failure, and those which may help clarify disease mechanisms are included.

Coronavirus disease 2019 (COVID-19) is a global pandemic that is wreaking havoc on the health and economy of much of human civilization. Electrophysiologists have been impacted personally and professionally by this global catastrophe. In this joint article from representatives of the Heart Rhythm Society, the American College of Cardiology, and the American Heart Association, we identify the potential risks of exposure to patients, allied healthcare staff, industry representatives, and hospital administrators. We also describe the impact of COVID-19 on cardiac arrhythmias and methods of triage based on acuity and patient comorbidities. We provide guidance for managing invasive and noninvasive electrophysiology procedures, clinic visits, and cardiac device interrogations. In addition, we discuss resource conservation and the role of telemedicine in remote patient care along with management strategies for affected patients.

This study investigated the association between left ventricular ejection fraction (LVEF) and the risk of ventricular arrhythmias (VA), heart transplantation, and death in cardiac sarcoidosis (CS). We identified 110 CS patients meeting 2014 Heart Rhythm Society (HRS) diagnostic criteria with baseline LVEF35% (n = 32) or ≥35% (n = 78). The primary end point was sustained VA or sudden cardiac death (SCD), and secondary end points included risk of heart transplantation, death, or a composite. Logistic regression determined risk factors for VA/SCD, and Cox proportional hazards regression analysis was performed for secondary end points. Receiver operating curve analysis determined the best discrimination point of LVEF for each end point; sensitivity analyses evaluated the effects of higher LVEF on each end point. Over a follow-up of 2.6 (range 1.0 to 5.8) years, 49 (44.5%) CS patients experienced VA/SCD, including 19 of 32 (59.4%) with LVEF35%, and 30 of 78 (38.5%) with LVEF ≥35%. After adjustment, LVEF35% was not significantly associated with an increased risk of VA/SCD compared with LVEF ≥35% (odds ratio 1.3, 95% confidence intervals 0.5 to 3.7). Although LVEF35% was associated with an increased risk of heart transplantation and death (28.1% vs 12.8%, p = 0.05), this was not significant after adjustment (hazard ratio 1.7, 95% confidence intervals 0.5 to 9.0, p = 0.53). In conclusion, patients with CS experience high rates of VA, SCD, and heart transplantation, even when LVEF is mildly impaired or normal. Patients with LVEF35% are at particularly elevated risk of VA/SCD. Our findings highlight the imperative to investigate arrhythmia risk in all patients with CS, even in the setting of an otherwise reassuring LVEF.

Sudden cardiac death (SCD) is defined as an unexpected death that occurs within a short time period (

Premature ventricular complexes (PVCs) are common arrhythmias in the clinical setting. PVCs in the structurally normal heart are usually benign, but in the presence of structural heart disease (SHD), they may indicate increased risk of sudden death. High PVC burden may induce cardiomyopathy and left ventricular (LV) dysfunction or worsen underlying cardiomyopathy. Sometimes PVCs may be a marker of underlying pathophysiologic process such as myocarditis. Identification of PVC burden is important, since cardiomyopathy and LV dysfunction can reverse after catheter ablation or pharmacological suppression. This state-of-the-art review discusses pathophysiology, clinical manifestations, how to differentiate benign and malignant PVCs, PVCs in the structurally normal heart, underlying SHD, diagnostic procedures (physical examination, electrocardiogram, ambulatory monitoring, exercise testing, echocardiography, cardiac magnetic resonance imaging, coronary angiography, electrophysiology study), and treatment (lifestyle modification, electrolyte imbalance, medical, and catheter ablation).

Background and Purpose— Emerging evidence suggests that an underlying atrial cardiopathy may result in thromboembolism before atrial fibrillation (AF) develops. We examined the association between various markers of atrial cardiopathy and the risk of ischemic stroke. Methods— The CHS (Cardiovascular Health Study) prospectively enrolled community-dwelling adults ≥65 years of age. For this study, we excluded participants diagnosed with stroke or AF before baseline. Exposures were several markers of atrial cardiopathy: baseline P-wave terminal force in ECG lead V 1 , left atrial dimension on echocardiogram, and N terminal pro B type natriuretic peptide (NT-proBNP), as well as incident AF. Incident AF was ascertained from 12-lead electrocardiograms at annual study visits for the first decade after study enrollment and from inpatient and outpatient Medicare data throughout follow-up. The primary outcome was incident ischemic stroke. We used Cox proportional hazards models that included all 4 atrial cardiopathy markers along with adjustment for demographic characteristics and established vascular risk factors. Results— Among 3723 participants who were free of stroke and AF at baseline and who had data on all atrial cardiopathy markers, 585 participants (15.7%) experienced an incident ischemic stroke during a median 12.9 years of follow-up. When all atrial cardiopathy markers were combined in 1 Cox model, we found significant associations with stroke for P-wave terminal force in ECG lead V 1 (hazard ratio per 1000 μV*ms 1.04; 95% confidence interval, 1.001–1.08), log-transformed NT-proBNP (hazard ratio per doubling of NT-proBNP, 1.09; 95% confidence interval, 1.03–1.16), and incident AF (hazard ratio, 2.04; 95% confidence interval, 1.67–2.48) but not left atrial dimension (hazard ratio per cm, 0.96; 95% confidence interval, 0.84–1.10). Conclusions— In addition to clinically apparent AF, other evidence of abnormal atrial substrate is associated with subsequent ischemic stroke. This finding is consistent with the hypothesis that thromboembolism from the left atrium may occur in the setting of several different manifestations of atrial disease.

Medical devices have been targets of hacking for over a decade, and this cybersecurity issue has affected many types of medical devices. Lately, the potential for hacking of cardiac devices (pacemakers and defibrillators) claimed the attention of the media, patients, and health care providers. This is a burgeoning problem that our newly electronically connected world faces. In this paper from the Electrophysiology Section Council, we briefly discuss various aspects of this relatively new threat in light of recent incidents involving the potential for hacking of cardiac devices. We explore the possible risks for the patients and the effect of device reconfiguration in an attempt to thwart cybersecurity threats. We provide an outline of what can be done to improve cybersecurity from the standpoint of the manufacturer, government, professional societies, physician, and patient.

Implantable cardioverter defibrillator (ICD) management complexities challenge the ethos of fully informed consent, particularly for the typically multimorbid elderly patient considering the device for primary prevention. The Heart Rhythm Society recommends providers include discussion on the potential need for later device deactivation or nonreplacement at the time of first implant, and to revisit this at appropriate intervals. The initial consent procedure could meet this standard by incorporating the future need to discuss further such issues when the recipient's clinical condition changes to such an extent that defibrillation would no longer be beneficial. At the time of obtaining consent, some patients may lack the will or capacity to make medically complex decisions when it would be necessary for healthcare surrogate decision-makers to contribute to this process. Ensuring an appropriate level of understanding and response may be enhanced by the use of information and decision aids. With improved communication regarding the nuances of ICD therapy, device eligible patients, and those close to them, will be empowered with a better understanding of the nature, benefits, and risks of ICD implantation, allowing them to make treatment decisions consistent with their values.

Eric S. Williams, MD, MACC, Chair Jonathan L. Halperin, MD, FACC, Co-Chair Jesse E. Adams III, MD, FACC James A. Arrighi, MD, FACC Eric H. Awtry, MD, FACC[†][1] Eric R. Bates, MD, FACC[†][1] John E. Brush, Jr, MD, FACC Lori Daniels, MD, MAS, FACC[†][1] Ali Denktas, MD, FACC Susan

A 63-year-old man with end-stage ischemic cardiomyopathy presented with incessant ventricular tachycardia. He had been hospitalized multiple times in the past year for severe heart failure. As he approached end of life and was regularly receiving defibrillator shocks, his care team recommended deactivation of his implantable cardioverter-defibrillator. However, his family did not wish to allow deactivation, reporting a religious obligation to prolong his life, regardless of the risk of suffering. The patient was unable to adequately participate in the decision-making process. An implantable cardioverter-defibrillator can serve to avoid sudden death but may lead to a prolonged death from heart failure. This possibility forces the examination of values regarding prolongation of life, sometimes producing disagreement among stakeholders. Although ethical consensus holds that defibrillator deactivation is legal and ethical, disagreements about life prolongation may complicate decision making. The ethical, technical, and medical complexity involved in this case speaks to the need for clear, prospective communication involving the patient, the patient's family, and members of the care team.

Background Despite data supporting the use of simulation training in procedural specialties and accreditation requirements, few options exist for electrophysiology (EP) training. We aimed to develop a low-cost, accessible simulator for training in EP mapping, and to test the simulator in a group of novice users. Methods Our mapping simulator is composed of three components: an acrylic case representing torso and thigh; three-dimensional (3D) printed cardiac models; and a commercially available mapping system. Using a proprietary flexible material that mimics the consistency of human heart tissue, we created an anatomically accurate model of a normal right atrium (RA) from computed tomography data. We developed a test protocol consisting of two activities: creation of a RA shell and timed navigation to specific locations within the RA shell. Seventeen participants were randomized to either practice versus no practice on the simulator, and repeated simulator and self-assessment tests were performed after 1 week. We measured volume of the RA map and time taken and distance from the target sites for each target location. Results Both groups showed improvement in generation of geometry, volume, time to target, and self-assessed comfort level after initial exposure to the simulator. Compared with no-practice, the practice group demonstrated an improved sense of confidence in mapping. Conclusions Focused training in EP mapping using a novel simulator created with 3D printed heart models and a standard mapping system is feasible for use in the training environment. Exposure to the simulator is associated with improved mapping skills and trainee comfort level.

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Background and Purpose— Depression is associated with stroke, but the effects of changes in depressive symptoms on stroke risk are not well understood. This study examined whether depressive symptom changes across 2 successive annual assessments were associated with incident stroke the following year. Methods— We used visit data from 4319 participants of the Cardiovascular Health Study who were stroke free at baseline to examine whether changes in depressive symptoms classified across 2 consecutive annual assessments predicted incident first stroke during the subsequent year. Depressive symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression scale (high versus low at ≥10). Survival models were inverse probability weighted to adjust for demographics, health behaviors, medical conditions, past depressive symptoms, censoring, and survival. Results— During follow-up, 334 strokes occurred. Relative to stable low scores of depressive symptoms, improved depression symptoms were associated with almost no excess risk of stroke (adjusted hazards ratio, 1.02; 95% confidence interval, 0.66–1.58). New-onset symptoms were nonsignificantly associated with elevated stroke risk (adjusted hazards ratio, 1.44; 95% confidence interval, 0.97–2.14), whereas persistently high depressive symptoms were associated with elevated adjusted hazard of all-cause stroke (adjusted hazards ratio, 1.65; 95% confidence interval, 1.06–2.56). No evidence for effect modification by race, age, or sex was found. Conclusions— Persistently high symptoms of depression predicted elevated hazard of stroke. Participants with improved depressive symptoms had no elevation in stroke risk. Such findings suggest that strategies to reduce depressive symptoms may ameliorate stroke risk.

We describe the case of a 49-year-old woman with metastatic renal carcinoma receiving treatment with high-dose interleukin-2 (IL-2) who developed acutely progressive dyspnea on exertion and an elevated troponin level. Cardiac magnetic resonance imaging (CMR) was used to establish the diagnosis of IL-2-associated cardiotoxicity, differentiating myocarditis from acute coronary syndrome (ACS) and preventing an unnecessary invasive coronary angiogram. .

Background The subcutaneous implantable cardioverter defibrillator (S-ICD) is a novel implanted defibrillator for the prevention of sudden cardiac death that avoids intravascular access. Use of this device is limited by its inability to provide backup pacing. Combined use of the S-ICD with a permanent pacemaker may be the optimal choice in certain situations though experience with the use of both devices together remains limited. Methods We reviewed our single-center experience with the S-ICD from March 2011 to November 2015. Four patients with concomitant use of the S-ICD and a permanent pacemaker were identified. Clinical indication for device therapy, operative details, and subsequent follow-up was reviewed. During implantation, S-ICD sensing of paced morphologies was evaluated at maximal voltage output. After S-ICD implant, if feasible, the upper rate was adjusted to ≤50% of the S-ICD tachycardia zone to minimize risk of inappropriate shocks. Results After a mean follow-up of over 1 year, no adverse events occurred, including no inappropriate shock, lead malfunction, or device infection. One patient had a total of eight appropriate shocks, while another individual had no inappropriate shocks despite having a unipolar pacing lead. Conclusions In unique situations, combined use of the S-ICD and a permanent pacemaker may be preferable to alternative options. In our experience, this approach was successful in varying conditions including complex congenital heart disease, recurrent device infection, and limited vascular access.

Left ventricular assist devices (LVADs) are an increasingly used strategy for the management of patients with advanced heart failure with reduced ejection fraction. Although these devices effectively improve survival, atrial and ventricular arrhythmias are common, predispose these patients to additional risk, and complicate patient management. However, there is no consensus on best practices for the medical management of these arrhythmias or on the optimal timing for procedural interventions in patients with refractory arrhythmias. Although the vast majority of these patients have preexisting cardiovascular implantable electronic devices or cardiac resynchronization therapy, given the natural history of heart failure, it is common practice to maintain cardiovascular implantable electronic device detection and therapies after LVAD implantation. Available data, however, are conflicting on the efficacy of and optimal device programming after LVAD implantation. Therefore, the primary objective of this scientific statement is to review the available evidence and to provide guidance on the management of atrial and ventricular arrhythmias in this unique patient population, as well as procedural interventions and cardiovascular implantable electronic device and cardiac resynchronization therapy programming strategies, on the basis of a comprehensive literature review by electrophysiologists, heart failure cardiologists, cardiac surgeons, and cardiovascular nurse specialists with expertise in managing these patients. The structure and design of commercially available LVADs are briefly reviewed, as well as clinical indications for device implantation. The relevant physiological effects of long-term exposure to continuous-flow circulatory support are highlighted, as well as the mechanisms and clinical significance of arrhythmias in the setting of LVAD support.

Introduction Meaningful feedback is essential for effective medical education, yet the feedback process has been consistently problematic for both learners and faculty. Emerging research on feedback highlights the importance of the learner, relationships, and culture for feedback to improve performance. We used the theory of self-regulated learning to develop the Prepare to Ask-Discuss-Ask-Plan Together (Prepare to ADAPT) framework to improve the feedback processes and investigated learner perceptions of this innovative feedback framework. Methods Qualitative thematic analysis of structured interviews of nine trainees participating in training on the Prepare to ADAPT feedback framework. Results The framework appeared primarily to potentially decrease learner anxiety and stress around the feedback process by providing a simple, structured discourse pattern. We identified five contributing themes: (1) increased efficiency of the feedback process; (2) formation of coaching/teamwork relationships; (3) facilitation of reflection and goal identification; (4) increased frequency of the feedback; (5) increased usefulness of the feedback. Discussion The Prepare to ADAPT framework may help decrease stress and anxiety of the feedback by clarifying the process, applying a structure, and developing coaching relationships. The framework was found to be easy to use and increased the number of effective feedback conversations in this exploratory study.

Objectives This study was conceived to determine the safety and efficacy of the subcutaneous implantable cardioverter-defibrillator (S-ICD) in patients with congenital heart disease (CHD). Background The S-ICD is a treatment option for patients with CHD in which a transvenous device is contraindicated due to anatomic considerations. However, efficacy in this group has not been determined. Methods A pooled analysis of 865 patients in the EFFORTLESS (Evaluation of Factors Affecting the Clinical Outcome and Cost-Effectiveness) registry (an international observational database) and a U.S. Investigational Device Exemption study were reviewed. Results Nineteen CHD patients versus 846 non-CHD patients with a median follow-up of 567 days and 639 days, respectively, were included. There were no deaths and no appropriate shocks for ventricular tachycardia/ventricular fibrillation in the CHD cohort, versus 26 deaths (3.1%, p = 0.42) and 111 appropriate shocks in 59 patients (7.1%) in the non-CHD cohort (p = 0.23). There were similar complication rates for the CHD versus non-CHD groups (10.5 vs. 9.6% [p = 0.89]), with inappropriate shocks for T-wave oversensing as the only complication in the CHD group (n = 2). The rate of inappropriate shocks was similar for both groups (10.5% vs. 10.9% [p = 0.96]). Successful defibrillation testing at 80J was comparable for the CHD versus non-CHD groups (100% vs. 98.5%). Conclusions The overall analysis of the CHD cohort from the pooled data of the Investigational Device Exemption study and the EFFORTLESS registry shows that the S-ICD is a safe option in CHD patients deemed to be at high risk for sudden cardiac death who do not have pacing indications. Further research to accurately define sudden cardiac death risk in the diverse anatomic substrates of CHD patients is warranted.

The early repolarization (ER) pattern (ERP), initially described as elevation of the ST segment of ≥1 leads on the 12-lead ECG, has long been considered a benign phenomenon. However, more recent studies have demonstrated positive, negative, and neutral associations between an ERP and various end points, including all-cause, cardiac, and arrhythmic mortality. These recent studies have used more complex or heterogeneous definitions of ER, including J-wave or J-point elevation and QRS complex notching or slurring, with or without concomitant ST-segment elevation. Other studies have identified an increased prevalence of ERP in survivors of spontaneous ventricular fibrillation (VF) or cardiac arrest. As a result, considerable confusion remains concerning the definition of ERP, its prognostic significance, and whether additional evaluation or treatment is warranted. These issues are especially important because the prevalence of ERP may be as high as 10% in the general population and even higher in some healthy subgroups. The writing group performed a comprehensive literature search and developed recommendations based on the results of the current literature. We searched MEDLINE (via PubMed), EMBASE, and the Cochrane Library to identify relevant primary scientific articles, guideline statements, and review articles in the literature. Search terms included, but were not limited to, early repolarization, J-point elevation, J wave, Haissaguerre syndrome, sudden cardiac death, idiopathic ventricular fibrillation, ventricular fibrillation, cardiac repolarization reserve, sudden unexplained death syndrome, and Osborn waves. We also reviewed the references of highly cited documents and citing documents. The recommendations were voted on, and 80% agreement was required for inclusion. The purposes of this document are as follows

Electrophysiology (EP) is an increasingly complicated field. Recognition of the complexity and scope of EP training has resulted in a consensus that it requires more than 12 months to become competent in the vast array of required decision-making and procedural skills. We aim to provide an update on