The author reviewed electrocardiographic records of 150 patients with acute stroke and 150 age- and sex-matched controls, to assess the relative frequencies of ECG abnormalities among the pathophysiologic categories of stroke, and to distinguish new abnormalities at the time of the stroke from those noted on prior tracings. Of the 150 patients with stroke, 138 (92%) showed ECG abnormalities. The most common abnormalities were also changes from prior tracings: QT prolongation (68 patients, 45%), ischemic changes (59, 35%), U waves (42, 28%), tachycardia (42, 28%), and arrhythmias (41, 27%). Patients with cerebral embolus had a significantly increased frequency of atrial fibrillation (9 patients, 47%); and with subarachnoid hemorrhage an increased frequency of QT prolongation (20, 71%) and sinus arrhythmia (5, 18%). The frequencies of QT prolongation and ischemic changes related strongly to admission systolic pressure but not to mortality. Stroke patients had an increased frequency of pathologic Q waves (30 patients, 20%) and left ventricular hypertrophy (39, 26%), but these were not new findings at the time of the stroke. The results are consistent with an interaction of underlying hypertensive or atherosclerotic cardiovascular disease, sympathetic hyperactivity, and possibly myocardial necrosis, in producing ECG changes.