Sudden cardiac death in young athletes is rare but tragic. The cardiology 
community is faced with the challenge of providing a sensible strategy for the 
prevention of SCD while simultaneously reaffirming that the benefits of regular 
exercise far outweigh potential risks. At present, there is a broad range of 
screening recommendations dependent upon country, sporting discipline, and 
competition level. While much recent debate has focused on the efficacy of 
screening with electrocardiography, a number of sporting bodies also mandate the 
inclusion of exercise testing and echocardiography in screening protocols. 
Cardiac magnetic resonance imaging, coronary calcium scoring and computed 
tomography coronary angiography have also been promoted as potentially valuable 
screening tools for competitive athletes. This review will examine the 
controversial topic of utilizing cardiac imaging for athlete pre-participation 
screening. Specifically, the limitations of screening for relatively rare 
disorders using imaging tools with uncertain or imperfect accuracy will be 
addressed. Current evidence suggests that the accuracy of all cardiac imaging 
modalities is insufficient to justify their use as primary screening modalities 
in athletes. Atypical findings such as marked cardiac dilation, reduced 
deformation, or small patches of delayed gadolinium enhancement may be commonly 
encountered in well-trained athletes, but, at present, the prognostic 
significance of such findings is unknown. Resulting uncertainty for the 
clinician and athlete has the potential for psychological stress, further 
testing, and unnecessary exclusions from competition. However, these concerns 
must not be confused with the extremely useful applications of cardiac imaging 
for the assessment of athletes with symptoms, an abnormal electrocardiogram or a 
positive family history. As modern imaging further enhances our understanding of 
the spectrum of athlete's heart, its role may expand from the assessment of 
athletes with suspected disease to being part of comprehensive pre-participation 
screening in apparently healthy athletes.