We read with interest the timely report by Devinsky, who reviewed the published research on sudden unexpected death in epilepsy. The investigator suggested the importance of pacemaker insertion in documented bradyarrhythmias and asystole in patients with epilepsy; the role of tachyarrhythmias, although reported, remains underexplored. There are several pathophysiologic events contributing to sudden unexpected death in epilepsy, including cardiac arrhythmias, respiratory dysfunction, and dysregulation of systemic or cerebral circulation, and it is very difficult to pinpoint one over another. Genetically, ion channel mutations seem to have an important role in intrinsic membrane excitability and could underlie epilepsy and cardiac arrhythmias that precipitate death. In a recent analysis, Badheka et al investigated the outcomes of 6 epileptic survivors of sudden cardiac death from the Antiarrhythmics Versus Implantable Defibrillators (AVID) study database. Analysis demonstrated that a history of epilepsy was a significant predictor of recurrent life-threatening ventricular arrhythmias (hazard ratio 3.53, 95% confidence interval 1.30 to 9.56), cardiac death (hazard ratio 4.14, 95% confidence interval 1.30 to 13.14), and all-cause mortality (hazard ratio 3.82, 95% confidence interval 1.40 to 10.48), suggesting a potential role for implantable cardioverter-defibrillator placement for primary and secondary prevention of sudden cardiac death. Abnormalities in cardiac repolarization have recently been described in patients with epilepsy. Importantly, peri-ictal ventricular tachycardia and fibrillation have also been reported in the absence of any underlying cardiac disease, especially in long-standing epilepsy. Therefore, pathologic cardiac repolarization could promote sudden cardiac death in patients with epilepsy and could be a plausible cause for sudden unexpected death in epilepsy. The important question is how we identify patients with epilepsy at a “higher” risk for developing tachyarrhythmias. Unfortunately, there are no data for risk stratification. Although we agree with the author’s recommendation for pacemaker implantation in patients with bradyarrhythmia (accounting for 0.5% to 2% of patients), tachyarrhythmias are reportedly more common (40% to 87%). The question of screening, prevention, and therapy of these tachyarrhythmias in high-risk patients with epilepsy warrants further investigation in the future. Until then, a multidisciplinary approach between cardiac electrophysiologists and neurologists is required to individualize treatment strategies in the prevention of sudden unexpected death in epilepsy. The identification of genetic and other risk factors that predispose patients with epilepsy to the development of cardiac arrhythmias and sudden death will be important in risk factor stratification and provide opportunities for therapeutic intervention (implantable cardioverter-defibrillators) to prevent sudden death in patients with epilepsy.