Primary care providers often are asked to perform the preparticipation physical exam and cardiac screening of pediatric athletes. It can be challenging to evaluate which athletes may require further cardiac evaluation and specialist referral based on a focused history and physical. There is considerable controversy surrounding mass electrocardiogram (ECG) screening of athletes in the United States. The ECG is one of several diagnostic tests used by pediatric cardiologists in the evaluation of underlying heart disease in young athletes. This article reviews cardiac conditions associated with sudden death, discusses pertinent findings on history and physical, and provides clinically relevant information for practitioners who are deciding which patients to refer for detailed cardiac evaluation.