Correlation Between Serum Ferritin and Electrocardiographic and Echocardiographic Markers of Cardiac Dysfunction in Children With Transfusion-Dependent β-Thalassemia Major

Background: Cardiac complications resulting from iron overload remain the leading cause of morbidity and mortality in children with transfusion-dependent β-thalassemia major.Early identification of myocardial dysfunction using non-invasive markers is essential, particularly in resource-limited settings where cardiac magnetic resonance imaging (MRI) T2* is not readily available.Objectives: To evaluate the correlation between serum ferritin levels and electrocardiographic and echocardiographic markers of cardiac dysfunction in children with β-thalassemia major.Methods: This analytical cross-sectional study was conducted in the Department of Pediatrics, Baba Raghav Das Medical College, Gorakhpur, India, from January 2025 to December 2025.Eighty children aged two to 16 years with transfusion-dependent β-thalassemia major were enrolled and stratified into three groups according to serum ferritin levels: <2500 ng/mL, 2500-5000 ng/mL, and >5000 ng/mL.All participants underwent clinical evaluation, electrocardiography (ECG), conventional echocardiography, and tissue Doppler imaging.Pearson correlation and multivariate linear regression analyses were performed.Results: Higher serum ferritin levels were associated with significant prolongation of the corrected QT (QTc) interval and QT dispersion and associated with impairment of left ventricular systolic and diastolic function.Serum ferritin showed significant negative correlations with left ventricular ejection fraction (LVEF) (r = -0.684),E/A ratio (r = -0.582),lateral early diastolic mitral annular velocity (r = -0.658),and tricuspid annular plane systolic excursion (r = -0.512),and positive correlations with the ratio of early transmitral flow velocity to early diastolic mitral annular velocity (E/Ea ratio) (r = 0.726), QTc interval (r = 0.648), and myocardial performance index (r = 0.672) (all p < 0.001).Multivariate analysis identified serum ferritin as the strongest independent predictor of reduced LVEF (β = -0.562,p < 0.001).Conclusions: Elevated serum ferritin levels are significantly associated with subclinical and overt cardiac dysfunction in children with β-thalassemia major.Combined assessment using serum ferritin, ECG, and echocardiography may facilitate early detection of iron overload cardiomyopathy and help optimize chelation therapy, particularly in settings where advanced cardiac imaging is unavailable.