Objectives. We sought to describe the mode of onset of spontaneous torsade de pointes in the congenital long QT syndrome. Background. Contemporary classifications of the long QT syndrome (LQTS) refer to the congenital LQTS as 'adrenergic dependent' and to the acquired LQTS as 'pause dependent.' Overlap between these two categories has been recognized, and a subgroup of patients with 'idiopathic pause-dependent torsade' has been described. However, it is not known how commonly torsade is preceded by pauses in the congenital LQTS. Methods. We reviewed the electrocardiograms (ECGs) of all our patients with congenital LQTS evaluated for syncope or sudden death (30 patients). Documentation of the onset of torsade de pointes was available for 15 patients. All these patients had 'definitive LQTS' by accepted clinical and ECG criteria. Results. Pause-dependent torsade de pointes was clearly documented in 14 of the 15 patients (95% confidence interval 68% to 100%). The cycle length of the pause leading to torsade was 1.3 ± 0.2 times longer than the basic cycle length, and most pauses leading to torsade were unequivocally longer than the preceding basic cycle length (80% of pauses were >80 ms longer than the preceding cycle length). Conclusions. The 'long-short' sequence, which has been recognized as a hallmark of torsade de pointes in the acquired LQTS, plays a major role in the genesis of torsade in the congenital LQTS as well. Our findings have important therapeutic implications regarding the use of pacemakers for prevention of torsade in the congenital LQTS.