SCA is a dynamic and unexpected event that remains a major and global public health problem. There can be multiple etiologies but coronary artery disease remains the major player. The initial approach to SCA requires a rapid community-based response. Specific guidelines are available for provision of pre-hospital care and methodology continues to evolve. However, even with rapid response, survival from SCA is extremely low and there is significant regional variation. For SCA victims that survive to reach the hospital, a careful step-wise approach to immediate care and subsequent identification of SCA etiology is advisable. While primary prevention for sudden death has come a long way, significant enhancement of risk stratification techniques is needed to maximize benefit and efficiency of health care utilization. The persisting low survival rates following SCA continue to emphasize that achievement of efficient risk stratification and primary prevention must remain our major target for management of SCA.