Early repolarization, involving infero-lateral ST segment elevation and prominent J waves at the QRS-ST junction has been considered a normal ECG variant for more than 80 years. More recent studies suggest that this phenomenon is not as benign as earlier believed and may represent a risk for subsequent ventricular fibrillation in patients with and without structural heart disease. However, based on current data it seems unjustified to consider these often accidental ECG findings a marker for high risk of sudden cardiac death. The concept of a reduced repolarization reserve developed for the Long QT syndrome can be transformed to early repolarization syndrome. In general a "fibrillation reserve" is relatively high but if triggers such as a genetic background, age, gender, influences of the autonomous nervous system, changes in body temperature, or an acute coronary syndrome act together ventricular fibrillation may occur. A combination of an "early repolarization ECG" with syncope and/or a positive family history of sudden cardiac death may justify defibrillator therapy just on an individual basis. This review intends to summarize actual aspects of early repolarizations syndrome and focuses on the dilemma of risk stratification.