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Osborn Waves are seen at the junction of the S wave and the ST segmant. They are seen as early
repolariation phenomena in healthy young adults (commonly males) but also are seen, inter alia, in
hypothermia and subarachnoid haemorrhage.
ICAO Preliminary Unedited Version — October 2008 III-App. 1A-3
The mean frontal QRS axis
The QRS-axis of the heart is normally 0º to +90º. Right axis deviation is present when the axis is >90º.
Leftward axis deviation is present between 0º and -30º, and left axis deviation is present when the axis is
> -30º.
— — — — — — — —
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-1
APPENDIX 1B.— ILLUSTRATIVE RESTING ELECTROCARDIOGRAMS
The following cases include a representative, but by no means complete, record of some commonly
encountered electrocardiographic patterns. They are illustrative only.
1. 28-year-old pilot, applying for class I medical assessment. The mean frontal QRS-axis is +60º.
There is a sinus bradycardia. The pilot is very slim and large voltages in the chest leads are
normal in a slim individual - the horizontal plane voltages obey the inverse square law. Osbornwaves1
at the point of take-off of the ST-segment are present in V4, V5, and V6. This is so-called
“early re-polarisation” and is a normal variant in this case.
1 Osborn-waves: positive deflections occurring at the junction between the QRS com plex and the ST-segment; also
known as J-waves. After J.J. Osborn, American physiologist (20th century).
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-2
2. 48-year-old air traffic controller with a heart rate of 72 bpm; the recording is normal. The
significant AC interference in the hexaxial leads underscores the difficulty in making accurate
measurements from poor quality recordings. Good technique is therefore vital.
There are no septal q waves in SI, aVL and V6: incomplete bundle branch block may be present.
As an isolated observation in an otherwise normal subject, this is likely to be innocent. It is also
seen in dilated, inter alia, in cardiomyopathy. Exercise ECG, even in the otherwise normal subject
may demonstrate repolarisation abnormality which will justify further investigation with
echocardiography /thallium MPI in cases of doubt.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-3
3a. 44-year-old private pilot with a heart rate of 52 bpm. Superficially, the recording resembles an
inferior myocardial infarction with a Q-wave in SIII and T-wave inversion (although the T-wave
is asymmetrically inverted). This is a left arm/left leg lead transposition.
I
II
III
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-4
3b. Here the leads are in the correct position and the recording is normal. Good technique is therefore
vital.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-5
4. 24-year-old CPL-holder with marked sinus arrhythmia and atrioventricular dissociation of the
first three complexes. There is junctional escape. This is not uncommon in fit young men
particularly at night. The pilot was asymptomatic and if an exercise recording had been
performed, it would have been normal. He was assessed as fully fit.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-6
5. 34-year-old airline pilot who demonstrates a normal resting electrocardiogram apart from a very
long PR-interval – 360 ms. The narrow width of the QRS segment suggests that the block is at the
level of the AV node. The situation is most often benign in young subjects, and fitness can be
granted without restriction provided the QRS segment is of normal width (<90 ms) and the PRinterval
shortens with exercise to <180 ms. There should be no evidence of decremental
conduction.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-7
6. 34-year-old ATPL-holder who demonstrates a heart rate of 62 bpm. The heart is vertically
disposed as evidenced by small voltages in S1 and prominent voltages in the inferior leads SII,
SIII and aVF. The T-waves are tall but asymmetric. The PR-interval is at the lower limit of
normal – 116 ms. Provided the applicant is asymptomatic and there is no history suggestive of
nodal reciprocating tachycardia; this is a normal variant.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-8
7. 40-year-old, asymptomatic PPL-holder with low right atrial rhythm. This is sometimes called
coronary sinus rhythm. The PR-interval is normal but the P-waves are inverted in SII, SIII and
aVF. It is a commonly a normal variant and should not interfere with certification in the absence
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Manual of Civil Aviation Medicine 1(108)
