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Up to two-thirds of deaths in recent studies of heart failure are classified as sudden deaths. Several studies, are, evaluting therapies to prevent sudden death from ventricular tachycardia and ventricular fibrillation in heart failure. There are a number of causes of sudden death that require a different approach to prevention. Although these causes are generally well recognized, their incidence in the outpatient heart failure populationn has been defined, Bradyarrhythmias can be due to conduction system disease. Reflex vagal discharges, respiratory disturbances during sleep, and endogenous adenosine release have also been theorized to play role. Patients with syncope or conduction system disease deserve careful assesment for possible pacemaker placement. Drugs that suppress sinus and atrioventricular, nodes should be avoided, Recurrent myocardial ischemia and infarction are potential causes of sudden death in patients with coronary artery disease and can present with bradyarrhythmias or tachyarrbythmias. Attention to detection and therapy for ischemia is important. Systemic and pulmonary emboli occasionally occur, although the incidence is low; Atrial fibrilation increases the risk of systemic emboli. Systemic anticoagulation is generally recommended for dilated heart failure. Hyperkalemia is a particularly important cause of in-hospital, unexpected cardiac arrest. Angiotensin-converting enzyme inhibitor therapy, potassium supplementation, and impaired renal perfusion all contribute to hyperkalemia. Serum potassium levels should be carefully monitored during institution of medications that alter potassium balance.