OBJECTIVE: to study the prevalence of coronary heart disease (CHD) and its clinical manifestations among Finnish elderly people in a cross-sectional epidemiological survey in the rural district of Lieto, southwestern Finland, with special emphasis on the overlap of CHD manifestations with electrocardiogram (ECG) findings and factors associated with CHD. DESIGN: observational population-based study. SETTING: Health Centre in Lieto, Finland, 1990-91. SUBJECTS: 488 men and 708 women aged 64-97 years. MAIN OUTCOME MEASURES: angina pectoris (AP) and dyspnoea were recorded using the London School of Hygiene cardiovascular questionnaires. Resting ECG findings were analysed and coded. Minnesota codes 1.1-1.3, 4.1-4.4, 5.1-5.3 or 7.1 were interpreted as ischaemic. The medical history of cardiovascular diseases was based on medical records. RESULTS: the prevalence of AP was 9.1% [95% confidence interval (CI): 6.7-12.0] among men and 4.9% (3.5-6.8) among women. The respective figures for myocardial infarction (MI) were 13.9% (10.9-17.0) and 6.5% (4.8-8.6). Ischaemic ECG findings were common: 32.9% (28.7-37.1) of men and 39.3% (35.7-43.0) of women had such changes, whereas only a minority of them reported typical AP. The total prevalence of CHD, including AP, MI, past coronary artery by-pass operation or angioplasty or ischaemic ECG findings, was 37.7% (33.4-42.0) in men and 42.0% (38.3-45.6) in women. Among men, a higher prevalence of CHD was associated with increasing age [odds ratio (OR) 1.81; 95% .CI: 1.20-2.73] and a history of having smoked in the past (OR 1.66; 1.06-2.59), whereas among women it was associated with increasing age (OR 2.02; 1.48-2.77) and a lower educational level (OR 2.30; 1.37-3.86). CONCLUSION: the prevalence of CHD among elderly people is high and the clinical picture of the disease is variable. The nature of CHD seems to be less severe among elderly women compared with men. Minor ECG changes, especially in the ST and T segments, are common with ageing and should not necessarily be interpreted as ischaemic. However, these findings combined with atypical chest pain or dyspnoea in an elderly person may indicate the possibility of CHD.