International Circulation:  Recent analysis of sudden cardiac death epidemiology showed that almost 2 thirds of SCD happened in patients with low to moderate risks or none risks. What’s your opinion about how to improve the risk identification and stratification procedure to predict and prevent SCD?

Win-Kuang Shen: It is very a difficult issue because it has a lot to do with cost effectiveness.  If we have a massive screening tool that is inexpensive then we could do that test on everyone and， even if the test has a reasonably modest sensitivity and specificity， if it is inexpensive then you can implement that evaluation.  There is not such tool available for sudden cardiac death to prevent.  For instance， in some European communities they have decided to take an electrocardiogram on every newborn then do an echocardiogram on every schoolchild.  Whether that is going to be effective， particularly cost effective， is hard to know.  My suggestion is that， in general， we will need to continue to fine-tune the existing predictors and risk factors in sudden cardiac death.  Whether we are ever going to be able to identify patients from the low risk population I don’t have a solution to that.  It is important to realize that whenever we think about risk stratification it is not a one-time test but it really needs to be repeated like for patients older than 50 years of age having one evaluation annually.  The risk stratification in a select population needs to be repeated on a regular basis.