The S1S2S3 electrocardiographic pattern — Prevalence and relation to cardiovascular and pulmonary diseases in the general population

Joonas Nurminen, Andrés Ricardo Pérez-Riera, Antonio Bayés de Luna, Kjell Nikus, Leo Pekka Lyytikäinen, Heini Huhtala, Markku Eskola, Mika Kähönen, Antti Jula, Terho Lehtimäki, Jussi Hernesniemi

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Background: There is lack of studies exploring the incidence and association with diseases of the S1S2S3 electrocardiogram (ECG) pattern in the general population. Subjects and methods: This population study included 6299 individuals aged 30+, and explored the prevalence and association between S1S2S3 and cardiovascular and pulmonary diseases. Criteria for the S1S2S3-I and S1S2S3-II ECG pattern were fulfilled when there was an S wave in the leads I, II and III, and the S-wave amplitude was greater than the R-wave amplitude in one or two of the leads, respectively. Results: The S1S2S3-I ECG pattern was found in 2332 subjects (36.9%). After age adjustment, hypertension was associated with S1S2S3-I (Odds ratio [OR] 1.25, 95% CI 1.12–1.41, p < 0.001). This age-adjusted association was statistically significant among men but not among women (OR 1.37, 1.16–1.62, p < 0.001 and OR 1.13, 0.97–1.33, p = 0.126, respectively). The S1S2S3-II ECG pattern was present in 193 subjects (3.1%). After age adjustment, heart failure proved to be associated with S1S2S3-II (OR 1.85, 1.18–2.90, p = 0.007). Dividing the population by sex, resulted in a statistically significant age-adjusted association for men but not for women (OR 2.30, 1.22–4.33, p = 0.010 and OR 1.59, 0.83–3.03, p = 0.159, respectively). Interactions with sex were statistically non-significant. Conclusion: In the general adult population, the prevalence of the S1S2S3 ECG pattern is markedly affected by the diagnostic ECG criteria. The S1S2S3-I pattern was associated with hypertension, while S1S2S3-II was associated with heart failure, and both associations were enhanced in men. The associations with other studied cardiovascular and pulmonary diseases were minor and not clinically useful for risk stratification.

Original languageEnglish
Pages (from-to)113-119
Number of pages7
JournalJournal of Electrocardiology
Publication statusPublished - Jul 2022
Publication typeA1 Journal article-refereed


  • ECG
  • General population
  • Normal variant
  • QRS axis
  • S1S2S3

Publication forum classification

  • Publication forum level 1

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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