appropriate large-scale screening strategy.28a Further study is necessary to determine if the threshold to maximize sensitivity and specificity is different at moderate or greater altitude, as the normal saturation of neonates at altitude is around 95%.29 In September 2011, the United States Secretary of Health recommended that pulse-oximetry screening before discharge should be added to the newborn screening panel for the early detection of critical CHD for all infants born in the United States By 2014, 43 of 50 states had instituted legislation or regulations mandating pulse-oximetry screening with seven states and the District of Columbia supporting pulse-oximetry screening as the standard of care with no legislation in place.30 There have not been many studies assessing the accuracy of screening since the implementation of universal pulse-oximetry screening An initial study in the UK in 2011 showed a false-positive rate of 0.8% with a negative predictive value of 99.7% Of 20,055 newborn infants, 24 had critical CHD Of these 24, 6 were not identified by pulse-oximetry screening The critical lesions most likely to be missed by using pulse oximetry as a screening method were obstructive arch lesions such as coarctation and interrupted aortic arch.31 In recent studies in the United States, pulse oximetry screening has been shown to be cost effective.32 Screening and Sudden Cardiac Death Primary Prevention of Sudden Cardiac Death: Screening With History and Physical Examination, Electrocardiography, and Echocardiography A fair amount of controversy exists with regard to primary strategies for the prevention of sudden cardiac arrest (SCA) and sudden cardiac death (SCD) The accepted standard had been for a thorough comprehensive and uniform screening history, family history, and physical examination as suggested by the American Heart Association with the documentation of 12 important points.33 The 12 important points that need to be reviewed are as follows: Family history Premature sudden death Heart disease in surviving relatives Personal history Heart murmur Systemic hypertension Fatigability Syncope Exertional dyspnea Exertional chest pain Physical examination Presence of a heart murmur Femoral pulses Stigmata of Marfan syndrome Blood pressure measurement This approach underscores the importance of the discovery of signs and symptoms that may ultimately uncover underlying at-risk abnormalities for sudden cardiac arrest However, the utility and success of this strategy is less than optimal Specifically, it has been difficult to thoroughly and uniformly achieve the above strategy Studies34,35 have suggested that, overall, the majority of states in the United States have not been able to adopt a strategy for covering the important points recommended by the American Heart Association As a result, several organizations, including the American Academy of Pediatrics, have suggested a uniform preparticipation form whereby the key questions are covered prior to sports participation.36 Several points must be emphasized Firstly, prevention of SCA and SCD cannot be discussed in the context of athletic participation only and cannot be directed only to athletes An “athlete” may be somewhat difficult to truly define specifically In addition, in that underlying and undiagnosed cardiac abnormalities, both structural and electrical, have the potential to cause SCA in any at-risk young person, the protection as well as the strategies for prevention should include all youth, not only those arbitrarily defined as athletes Secondly, the efficacy of the history, family history and physical examination is far from perfect Though there are some retrospective studies that suggest that as many as 25% to 50% of those who experienced SCD had antecedent symptoms such as syncope, palpitations, or chest pain, the majority of studies have shown a relatively low yield for this strategy.37–39 And of course the individual who truly has no symptoms, has a negative family history, and a normal physical examination will not be uncovered by this strategy for discovery and prevention In 2006, Corrado published a study outlining the results of 25 years of a mandatory electrocardiography (ECG) screening program for competitive athletes in the Veneto region of Italy.40 Corrado's study showed a 90% reduction in the incidence of SCD in the athletic population by prospectively identifying those athletes with arrhythmogenic right ventricular dysplasia (ARVD) and hypertrophic cardiomyopathy (HCM) and subsequently excluding them from athletic participation However, studies by other investigators were not able to reproduce this experience Maron did not find similar outcomes in a study reported from Minnesota in 200941 and Steinvil (2011)42 did not find a reduction in the risk of SCD in athletes in Israel with their mandatory ECG screening program in 2011.42 However, tremendous controversy has been generated by this work Concerns include reproducibility of the data, ethical considerations regarding selecting specific populations and autonomy, generalizability to heterogeneous populations, effects of false positives and negatives, and cost considerations The American Heart Association has not yet embraced and recommended a strategy for mass ECG screening for young athletes in the ... the important points recommended by the American Heart Association As a result, several organizations, including the American Academy of Pediatrics, have suggested a uniform preparticipation form whereby the key questions are covered prior to sports participation.36 Several points must be emphasized