The sudden death of a young athlete on the playing field remains the most devastating medical event in sports, with compelling reasons to implement effective preventive strategies. Preparticipation screening is widely practiced, but universal agreement regarding the most appropriate method for cardiovascular screening is lacking. The addition of a resting 12-lead electrocardiogram (ECG) to a comprehensive personal and family history and physical examination will increase detection of those athletes with potentially lethal cardiovascular disorders at risk for sudden cardiac death. However, complex issues regarding feasibility, false positive results, cost-effectiveness, and physician and health system infrastructure still remain regarding large-scale implementation of ECG screening in the United States. When used, ECG interpretations based on modern criteria to distinguish abnormal findings from physiologic alterations in athletes must be applied to ensure acceptable accuracy.