Both the American Heart Association and the European Society of Cardiology consensus panel recommendations agree that cardiovascular screening for young competitive athletes is justifiable and compelling on ethical, legal, and medical grounds. However, there is a considerable discordance in the consensus guidelines on the pre-participation screening protocols used among European and US cardiologists/sports medicine physicians, with and without 12-lead electrocardiogram (ECG). In 1982 a nationwide program of pre-participation screening including ECG was launched in Italy. The aim of this article is to examine whether this long-running screening program should be considered a valid and advisable public health strategy. The analysis of data coming from the Italian experience indicates that ECG screening has provided adequate sensitivity and specificity for detection of potentially lethal cardiomyopathy or arrhythmias and has led to substantial reduction of mortality of young competitive athletes by approximately 90%. Screening has been feasible thanks to the Italian Health System, which is developed in terms of healthcare and prevention services, and because of the limited costs of cardiovascular evaluation in the setting of a mass program. The available scientific evidence suggests to adopt a screening protocol including ECG, which is the only screening tool proved to be effective. This article will also address the available data and criticisms concerning the screening program to prevent sudden cardiac death of middle-aged/senior athletes engaged in leisure-time sports activity.