Sudden cardiac death (SCD) from ventricular arrhythmias (VAs) remains a leading cause of mortality worldwide. Traditional risk stratification, primarily based on left ventricular ejection fraction (LVEF) and other coarse metrics, often fails to identify a large subset of patients at risk and frequently leads to unnecessary device implantations. Advances in artificial intelligence (AI) offer new strategies to improve both long-term SCD risk prediction and near-term VAs forecasting. In this review, we discuss how AI algorithms applied to the 12-lead electrocardiogram (ECG) can identify subtle risk markers in conditions such as hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), and coronary artery disease (CAD), often outperforming conventional risk models. We also explore the integration of AI with cardiac imaging, such as scar quantification on cardiac magnetic resonance (CMR) and fibrosis mapping, to enhance the identification of the arrhythmogenic substrate. Furthermore, we investigate the application of data from implantable cardioverter-defibrillators (ICDs) and wearable devices to predict ventricular tachycardia (VT) or ventricular fibrillation (VF) events before they occur, thereby advancing care toward real-time prevention. Amid these innovations, we address the medicolegal and ethical implications of AI-driven automated alerts in arrhythmia care, highlighting when clinicians can trust AI predictions. Future directions include multimodal AI fusion to personalise SCD risk assessment, as well as AI-guided VT ablation planning through imaging-based digital heart models. This review provides a comprehensive overview for general medical readers, focusing on peer-reviewed advances globally in the emerging intersection of AI, VAs, and SCD prevention.

Background: Atrial high‐rate episodes (AHRE) detected by cardiac implantable electronic devices (CIEDs) are associated with increased thromboembolic risk, yet their clinical significance and optimal anticoagulation strategy remain uncertain, particularly in the absence of electrocardiogram (ECG)‐confirmed atrial fibrillation. Methods: We conducted a nationwide cross‐sectional survey of UK clinicians involved in CIED follow‐up. The survey assessed anticoagulation decision‐making in AHRE, including episode‐duration thresholds, cumulative burden, CHA ₂ DS ₂ ‐VA use, additional ECG monitoring, and anticoagulant choice. Only responses from UK‐based consultant clinicians were included and analysed descriptively. Results: A total of 51 responses were received; 38 met the inclusion criteria and were analysed. Most respondents (86.8%) reported having reviewed AHRE alerts within the preceding 6 months, indicating that AHRE are commonly encountered in clinical practice. A ≥ 24‐h episode was the most common threshold for anticoagulation (44.7%), although many clinicians reported lower thresholds or individualised approaches. Nearly half (44.7%) did not consider cumulative AHRE burden in decision‐making. CHA ₂ DS ₂ ‐VA thresholds also varied, most commonly ≥ 2 or ≥ 1. Additional ECG monitoring was infrequently performed. Direct oral anticoagulants were universally preferred, with apixaban the most commonly selected agent (73.7%). Conclusion: There is substantial variation in UK clinical practice regarding anticoagulation for AHRE, reflecting ongoing uncertainty and lack of clear guidance. These findings highlight the need for evidence‐based thresholds to support consistent and informed clinical decision‐making.

Pacing-induced cardiomyopathy (PICM) is a recognized complication of pace-and-ablate therapy. Early identification of patients at risk may allow tailored strategies, including upfront biventricular or conduction system pacing. This study aimed to identify predictors of PICM in patients undergoing pace-and-ablate therapy, combining expert consensus with clinical validation. A three-round Delphi process involving 12 electrophysiologists prioritized candidate predictors of PICM. Consecutive patients undergoing atrioventricular node ablation with non-cardiac resynchronization therapy (CRT) devices at Liverpool Heart and Chest Hospital (2015–2019) were retrospectively analysed. The primary endpoint was PICM, defined as ≥10% reduction in left ventricular ejection fraction (LVEF) to <50%, adjudicated by two independent cardiologists. Cox regression was used to identify independent predictors. The Delphi process prioritized baseline LVEF, intrinsic and paced QRS duration, RV lead position, and key comorbidities. Among 658 ablation patients, 323 (median age 76 years, 67% female) had non-CRT devices. Over a median follow-up of 192 days (IQR, 63–1003 days), 33 patients (9.8%) developed PICM. In multivariable analysis, RV free wall vs. septal lead position [hazard ratio (HR) 4.896, 95% confidence interval (CI) 1.263–18.973, P = 0.022], intrinsic QRS duration (HR 1.247 per 10 ms, 95% CI 1.064–1.462, P = 0.006), independently predicted PICM. Exploratory analyses suggested that higher intrinsic QRS duration was associated with increased PICM risk; however, these findings were based on a small number of events and should be interpreted with caution. Intrinsic QRS duration and free wall RV lead position independently predict PICM in pace-and-ablate patients. These findings support early risk stratification and may guide personalized pacing strategies.

Background: Atrial high-rate episodes (AHRE) detected by cardiac implantable electronic devices (CIEDs) are associated with increased thromboembolic risk, yet their clinical significance and optimal anticoagulation strategy remain uncertain, particularly in the absence of electrocardiogram (ECG)-confirmed atrial fibrillation. Methods: We conducted a nationwide cross-sectional survey of UK clinicians involved in CIED follow-up. The survey assessed anticoagulation decision-making in AHRE, including episode-duration thresholds, cumulative burden, CHA ₂ DS ₂ -VA use, additional ECG monitoring, and anticoagulant choice. Only responses from UK-based consultant clinicians were included and analysed descriptively. Results: A total of 51 responses were received; 38 met the inclusion criteria and were analysed. Most respondents (86.8%) reported having reviewed AHRE alerts within the preceding six months, indicating that AHRE are commonly encountered in clinical practice. A ≥24-hour episode was the most common threshold for anticoagulation (44.7%), although many clinicians reported lower thresholds or individualised approaches. Nearly half (44.7%) did not consider cumulative AHRE burden in decision-making. CHA ₂ DS ₂ -VA thresholds also varied, most commonly ≥2 or ≥1. Additional ECG monitoring was infrequently performed. Direct oral anticoagulants were universally preferred, with apixaban the most commonly selected agent (73.7%). Conclusion: There is substantial variation in UK clinical practice regarding anticoagulation for AHRE, reflecting ongoing uncertainty and lack of clear guidance. These findings highlight the need for evidence-based thresholds to support consistent and informed clinical decision-making.

Background: Contemporary AF ablation practice has changed rapidly with the introduction of newer energy-delivery platforms. How these changes translate into longitudinal patterns of technology use and procedural characteristics within routine electrophysiology services is less well described. Methods: We performed a retrospective, procedure-level longitudinal service evaluation of AF ablations performed between April 2014 and June 2025 at a United Kingdom (UK) tertiary center. Index and repeat procedures were included. We describe annual technology use and observed skin-to-skin procedure time, fluoroscopy time, and dose-area product (DAP). These are operational measures, not surrogate clinical endpoints. We undertook no adjusted comparative analysis because technology choice was coupled with calendar era and relevant clinical and operator-level covariates were incomplete. Results: The analysis included 2862 procedures, comprising 1878 (66%) radiofrequency ablation (RFA), 735 (26%) cryoballoon, and 249 (9%) pulsed field ablation (PFA). RFA remained the predominant approach until 2020, cryoballoon use peaked in 2018 (n = 138), and PFA increased from 56 procedures in 2023 to 98 in 2024 and 95 in the first half of 2025. The median skin-to-skin time changed from 205 min in 2014 to 104 min in 2025. Observed median fluoroscopy time changed from 32 to 13 min, and median DAP from 3405 to 782 Gy.cm². Conclusions: Over 11 years, the centre experienced a marked change in AF ablation practice, characterised by the progressive adoption of newer technologies, alongside lower recorded procedure durations and radiation exposure. These observations describe service-level temporal trends and should not be interpreted as evidence that any individual ablation modality caused the observed changes or improved clinical outcomes.