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The appropriate screening strategy to prevent sudden cardiac death (SCD) in athletes remains a challenging and a highly debated issue. The purpose of this review is to examine the added value and controversies of including a 12-lead electrocardiogram (ECG) in addition to a comprehensive personal and family history during preparticipation screening of cardiovascular abnormalities in athletes.Studies in support of ECG screening are evolving rapidly, utilizing more rigorous ECG criteria with a lower total positive rate– and thus reduced levels of false positives. Reported estimates on the incidence of SCD in young athletes vary widely based on the methods of data collection and have likely underrepresented the incidence of SCD with implications on screening recommendations. More accurate calculations of SCD incidence combined with lower total positive rates yield a promising cost-effectiveness analysis in favor of universal ECG screening of athletes.The devastating impact of SCD in young athletes warrants the commitment of additional resources to identify those at risk. It is time for a systematic preparticipation screening program for all competitive athletes, using at least a standardized comprehensive personal and family history questionnaire and a screening ECG at the time of matriculation to high school and college. Although additional outcomes-based research is required, improved efforts to expand the infrastructure necessary for effective cardiac screening in young athletes are recommended.