Deaths of young athletes from cardiac disease are uncommon but receive considerable media attention and intermittently galvanize debates about cardiac screening prior to participation in sports. Both the American Heart Association (AHA) and European Society of Cardiology (ESC) endorse preparticipation screening in athletes; however, there is disagreement about the best approach. The AHA recommends history and physical examination; this approach is pragmatic and relatively inexpensive but has poor sensitivity because most athletes are asymptomatic and physical examination identifies only a minority of those at risk of sudden cardiac death. The inclusion of the electrocardiogram in accordance with the recommendations of the ESC improves sensitivity for detection of serious cardiac disease but is associated with an unacceptably high false-positive rate, in part because of the overlap between the electrical manifestations of athletic training and the cardiomyopathies. For young athletes with normal electrocardiogram results, echocardiography contributes minimally to the diagnosis of serious cardiac diseases. Given all the complexities, cardiac screening of young athletes should be voluntary not mandatory and conducted by highly experienced physicians who fully understand the cardiovascular adaptation to intensive exercise.