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Electrocardiography (ECG) has been proposed as a method to enhance the ability of the preparticipation examination (PPE) to detect underlying cardiac conditions that can lead to sudden cardiac death (SCD) in young athletes.We conducted a Medline review of the published medical literature, using the key terms of cardiovascular screening of athletes, ECG in athletes, SCD in athletes, and ECG in specific cardiac disease states: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, dilated cardiomyopathy, myocarditis, long QT syndrome, Brugada syndrome, coronary artery anomalies, myocardial bridging, aortic stenosis, mitral valve prolapse, and Marfan syndrome. ECG seems to increase the sensitivity of the PPE from 2.5-6% to 50-95%. Overall sensitivity appears to be about 50%; false-positive rates can be as high as 40%, and there is at least a 4-5% false-negative rate. In Europe, ECG-based screening programs have been associated with a decline in the SCD rate in young athletes, but similar programs are currently not recommended in the United States for many reasons: lack of randomized trial data; cost of screening; lack of a clear standard for ECG interpretation in the athlete; the likelihood that asymptomatic athletes with underlying lethal conditions might differ significantly from symptomatic individuals with the same conditions; and concern that ECG screening might actually increase the death rate, via treatment-related procedural complications.Although some authorities advocate the use of ECG screening of young athletes, further studies are required to define what constitutes a normal ECG in athletes, and to determine whether ECG-based screening protocols truly are superior, not only in finding disease, but also saving lives. For those who either choose ECG-based screening or interpret ECG in athletes, we propose a simple interpretation scheme and decision tree.