Does epicanthal folds always mean down syndrome?

No. Epicanthal folds can also be seen in asians, russians, and other races/cultures. In Down syndrome there are other features such as hypotonia, wide space between 1st and 2nd toe. There is a 50% chance of heart defects as well. The palpebral fissues (the eyelid opening) slants upward. The 5th finger is often short and curves inward. There are many other features with down syndrome.