Recently, early repolarization or J-point elevation in the inferior and lateral leads has been shown to be more common in patients with idiopathic VF compared with controls (26- 27). Although the association appears to be quite strong, the risk of an adverse event when confronted with an asymptomatic patient with early repolarization remained unknown. Investigators in Finland examined the baseline electrocardiograms (ECGs) in 10,864 subjects in the Social Insurance Institution's Coronary Heart Disease Study that were obtained between 1966 and 1972 (28). Early-repolarization patterns were sought in the inferior and lateral leads and stratified according to the degree of J-point elevation (≥0.1 or ≥0.2 mV) that was either notched or slurred in 2 consecutive leads. The cause of death was determined by examining death certificates. All deaths from a cardiac cause were then reviewed, including review of hospital records, to determine whether the death was likely associated with an arrhythmia or not. J-point elevation of at least 0.1 mV was present in 630 (5.8%) of participants at baseline. Those with inferior lead J-point elevation were more often male, smokers, had a lower resting heart rate, a lower body mass index, lower blood pressure, a shorter QTc interval, a longer QRS duration, and were more likely to have ECG evidence of coronary artery disease. Those with lateral J-point elevation were more likely to have left ventricular hypertrophy. During follow-up of 30 ± 11 years, 613 (56.5%) patients died. Of these deaths, 1,969 (32%) were due to cardiac causes, and of those, 795 (40%) were sudden. Before and after multivariable adjustment, subjects with J-point elevation of at least 0.1 mV in the inferior leads (n = 384) had a higher risk of cardiac death (adjusted relative risk: 1.28, 95% CI: 1.04 to 1.59, p = 0.03) and arrhythmic death (adjusted relative risk: 1.43, 95% CI: 1.06 to 1.94, p = 0.03). However, these patients did not have a significantly higher rate of all-cause mortality. Before and after multivariable adjustment, subjects with J-point elevation of >0.2 mV (n = 36) had an increased risk of cardiac death (adjusted relative risk: 2.98, 95% CI: 1.85 to 4.92, p = 0.03), arrhythmic death (adjusted relative risk: 3.94, 95% CI: 1.96 to 7.90, p = 0.03), and death from any cause (adjusted relative risk: 1.54, 95% CI: 1.06 to 2.24, p = 0.03). Although J-point elevation in the lateral leads was associated with arrhythmic death, it predicted cardiac and all-cause death with borderline significance. Early repolarization appears to be associated with worse cardiovascular outcomes, but the exact mechanism remains to be elucidated. The mechanism may also differ between patients. Although the event rates were relatively high, particularly in those with J-point elevation >2.0 mV, the follow-up was quite long. Additional research is needed to narrow down the particular patients at highest risk and to inform us about screening strategies and ultimately preventive therapies. It does appear that inferior lead J-point elevation and particularly prominent J-point elevation may be important risk factors.