Background It is commonly held that a normal ECG rules out the diagnosis of heart failure1; however this has only been demonstrated in the elderly.2 Do young people with heart failure always have major ECG abnormalities?

Aim To determine the proportion of patients aged below 65 who had heart failure with LVSD who present with ECGs without major abnormalities.

Methods 100 consecutive admissions to the Scottish National Advanced Heart Failure Service at the Golden Jubilee National Hospital, Glasgow who were aged below 65 and had an echocardiogram and ECG available. Ejection fraction was quantified using the Simpson's biplane method. ECGs were independently assessed by two cardiologists blinded to the result of the echocardiograms. Any disagreements were resolved by a third cardiologist. Majorly abnormal ECGs contained ≥1 of: Q-waves, left ventricular hypertrophy (LVH), bundle branch block and atrial fibrillation. Presence of Q waves was assessed subjectively by the two assessors and then using criteria as defined by the Universal Definition of Myocardial Infarction by a third assessor. Similarly the presence of LVH was assessed subjectively and using the Sokolow-Lyon Index. Minor abnormalities of ECG included atrial enlargement, bradycardia, tachycardia, broadening of QRS complex, poor R wave progression, left or right axis deviation, myocardial ischaemia, first degree atrioventricular block, and non-specific ST-T wave changes.

Results Of 100 consecutive patients, 77 were males and 23 females. Mean age was 50 years (range 18–64). 76 had major ECG abnormalities. 22 had only minor ECG abnormalities and no major ECG abnormalities; two had no abnormalities. All patient groups had marked LV systolic dysfunction (ejection fractions of 28.6% ±2.8, 28.4% ±3.4, 25.5% ±6.9 for those with major, minor and no abnormalities on ECG respectively). Analysis by criteria for Q waves demonstrated 71 had major ECG abnormalities, 27 had minor ECG abnormalities and 2 had none. Analysis by criteria for LVH gave the same results as the initial cardiological analysis.

Conclusion Only 71%–76% of patients under the age of 65 have major ECG abnormalities, compared to 98% of patients of any age (2). Young patients with heart failure often have minor ECG abnormalities in the absence of major ECG abnormalities. The index of suspicion of heart failure in young symptomatic patients should be high even in the absence of major ECG.