The purpose of this review is to examine the evidence surrounding the recommendations for cardiovascular screening in young competitive athletes. Sudden cardiac death (SCD) is the leading medical cause of death in athletes. There is widespread agreement that the primary purpose of the pre-participation cardiovascular screening examination is to identify athletes with conditions that predispose them to SCD. This can help inform the athlete of risks associated with exercise, define which athletes should pursue medical management for their condition, determine eligibility for competition, and delineate first-degree relatives who may need additional cardiac testing. Current cardiovascular screening with a traditional history and physical examination does not detect the majority of athletes at risk and provides false reassurance for those with silent underlying cardiovascular conditions. The addition of an electrocardiogram (ECG) enhances disease detection capabilities and modern athlete-specific ECG interpretation standards provide low false positive rates and improved cost efficiency. Future efforts should focus on physician education of ECG interpretation criteria, the development of an infrastructure to optimize cardiovascular screening, and providing evidence-based management strategies for athletes diagnosed with cardiac disorders. The goal of pre-participation screening is to identify athletes at risk for SCD. Advanced cardiovascular screening protocols have the potential to improve the health and safety of sport and should be considered in young competitive athletes, especially those deemed high risk.