Sudden cardiac death is a tragic event under any circumstances, but it is especially devastating when it occurs in youth and athletes. In the “paradox of sports,” exercise both promotes health and is associated with risk of sudden cardiac arrest or death (SCA/D) among those with underlying heart disorders, including hypertrophic cardiomyopathy (HCM). Developed societies agree that pre-participation screening is valuable and warranted to improve the detection of conditions that are associated with risk of SCA/D, leading to appropriate downstream risk stratification and interventions as needed. Current ACC/AHA guidelines have moved towards an “identify and risk stratify” approach for those with HCM rather than universal disqualification. However, there remain differences in opinion regarding the best methods for identifying athletes that may be at risk for SCA/D. A high-quality cardiovascular history and physical is uniformly employed and essential for screening. The addition of an ECG increases sensitivity for identifying cardiovascular conditions associated with SCA/D. European societies are generally in favor of including ECG testing within screening programs, and while US guidelines do not support widespread universal ECG screening, if employed in a systematic manner with appropriate resources, including personnel and downstream planning, then the ECG can be considered a useful addition to screening. Athlete-specific ECG criteria decrease the false-positive rate and downstream costs of screening, though additional cardiac imaging for abnormal findings may be required. Use of echocardiography does not have a role as a primary component of screening in the majority of athlete populations. Finally, HCM and other diseases are not always discovered with screening, and detection of cardiovascular risk does not prevent every SCA/D. Thus, patients with known cardiovascular risk and teams in general should have emergency action plans, understand CPR, and have access to defibrillators.