In a population-based study, the routine 12-lead electrocardiogram was found to have a high negative predictive value for detecting left ventricular (LV) systolic dysfunction. Withholding echocardiography in persons without major electrocardiographic abnormalities, however, would result in a considerable underestimation of LV systolic dysfunction (sensitivity only 54%); thus, echocardiography remains an essential tool for detecting LV systolic dysfunction in population-based studies.