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Background Wolff-Parkinson-White (WPW) syndrome poses a risk for tachyarrhythmias and sudden cardiac death. Most WPW studies have relatively limited numbers of subjects and brief follow-up periods. Methods We reviewed records of 238 consecutive military aviators with WPW syndrome evaluated from 1955 to 1999. Follow-up was by questionnaires, telephone interviews, or death certificates. Events included sudden cardiac death and supraventricular tachycardia (SVT) (by electrocardiographic [ECG] documentation or suggestive symptoms). Results The mean age was 34.3 years (range 17-56 years). Forty-two (42/238, 17.6%) had SVT (WPW syndrome) and 196 of 238 (82.4%) had the WPW ECG pattern only. The mean follow-up of 21.8 years (range 2-41 years) was obtained on 228 of 238 (96%) for a total of 4906 patient-years. Sudden cardiac death occurred in 1 of 228, an incidence of 0.0002 per patient-year (95% confidence interval 0.0-0.001). SVT occurred in 47 of 228 (20.6%) or 0.01 per patient-year. One hundred eighty-seven (187/228, 82%) initially had the WPW ECG pattern only; 28 of 187 (15.0%) reported SVT during follow-up. Forty-one (41/228, 18%) initially had WPW syndrome; 19 of 41(46.3%) reported additional SVT during follow-up. Conclusion Sudden cardiac death risk was low (0.02%/patient-year) in this WPW population. The SVT incidence was 1% per patient-year. Referral bias and some characteristics of the unique military aviator population may partly account for these low event rates. However, these results may be more applicable to unselected populations than are tertiary referral-based studies. (Am Heart J 2001;142:530-6.)