In asphyxiated neonates, hypoxia is often responsible for myocardial ischaemia. To evaluate cardiac involvement in neonates with respiratory distress, ECG and echocardiographic recordings were performed, and cardiac enzymes determined. These data were related to clinical presentation and patient outcome. Three groups of neonates were studied: 22 healthy newborn infants (group I) with 5 min Apgar scores > 9 and pH > 7.3; 15 neonates with moderate respiratory distress (group II) which had Apgar scores ranging between 7 and 9, and pH between 7.2 and 7.3; and 13 neonates with severe asphyxia, Apgar scores < 7, and pH < 7.2 (group III). The ECGs were evaluated according to the 4-grade classification proposed by Jedeikin et al. [8]. On the echocardiograms, fractional shortening and aortic flow curve parameters were taken into account. Serum creatine kinase (CK), creatine kinase-MB isoenzyme (CK-MB) and lactate dehydrogenase were determined. All of groups I and II survived, but 5 out of 13 in group III died within the 1st week. Grade 3 or 4 ECG changes were observed only in group III patients, while all group II and 3 patients of group I showed grade 2 ECG changes. Fractional shortening, peak aortic velocity and mean acceleration were significantly reduced in group III, whereas the only abnormality found in group II was a reduced fractional shortening. CK, CK-MB, CK-MB/CK ratio and lactate dehydrogenase were all increased in group III, while in group II only CK-MB and the CK-MB/CK ratio were abnormal. Severely asphyxiated newborn infants reflect relevant ischaemic electrocardiographic changes, depressed left ventricular function and marked cardiac enzyme increase. These alterations are far less pronounced in neonates with mild respiratory distress.