Sudden cardiac death (SCD) is a catastrophic event that can occur in apparently healthy athletes, often during training or competition. Despite advances in diagnostics, SCD remains a major public health concern, underscoring the critical role of primary care in prevention, risk stratification, and early detection. Primary care clinicians are frequently responsible for pre-participation evaluations, yet face challenges in balancing effective screening with resource limitations and ethical considerations.A 19-year-old competitive runner attended a routine pre-participation check-up in primary care. The consultation raised questions about the adequacy of standard screening protocols, which typically rely on history and physical examination alone. Should electrocardiography (ECG) be added? What are the implications of false positives, cost, and psychological impact? This reflection integrates clinical experience with current evidence and international guidelines, comparing approaches that include ECG versus those that do not. Key risk factors considered were inherited cardiomyopathies, arrhythmias, and family history of premature cardiac events. Practical barriers such as access to investigations, cost-effectiveness, and downstream consequences were critically examined.This case-based reflection highlights the complexity of screening athletes for SCD in primary care, where decisions must balance preventive benefit with feasibility and equity. It emphasizes ethical and psychological dimensions often overlooked in discussions focused solely on diagnostic accuracy.Primary care clinicians can adopt a tiered approach: comprehensive history and physical examination for all athletes, with ECG reserved for those with red flags such as family history or abnormal findings. Shared decision-making and psychological support are essential. Digital tools and telemedicine can enhance feasibility and reduce unnecessary referrals.Primary care plays a pivotal role in preventing SCD among athletes, yet screening programmes face limitations in predictive value and implementation. Collaborative guidelines, clinician education, and integration of emerging technologies may improve effectiveness while reducing harm.Preventing SCD in athletes requires a balanced, evidence-based approach that combines clinical vigilance, ethical safeguards, and practical implementation. Primary care clinicians are central to delivering accessible and equitable strategies that support informed decision-making and early intervention.