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of other abnormality.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-9
8. 31-year-old airline pilot who was in the habit of running 50 miles a week. There is rightward axis
deviation. The voltages are prominent and the T-waves inverted/notched V1 – V3. Thallium
scanning was negative. This variant is sometimes seen in the “athlete’s heart”. T wave inversion
is not abnormal in V1 and if present should diminish progressively, sometimes as notching, in V2
and V3. T wave inversion in V3 should be regarded as abnormal and is seen in right ventricular
abnormality, and in anterior ischaemia.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-10
9. 38-year-old asymptomatic CPL-holder who demonstrates the S1, 2, 3 syndrome in which all the
deflections in the hexaxial leads look very similar. S-waves are also seen in V5 and V6. This is a
normal variant. In an older age group, if a new change, the possibility of anteroseptal injury
needed to be considered and excluded.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-11
10. 21-year-old Class I applicant who demonstrates sinus rhythm at a heart rate of 84 bpm. There is
loss of amplitude of the T-waves in the inferior and left chest leads. This is a normal variant in a
young person, and a normal response to exercise is to be expected. There is a point of comment
with regard to the U waves which are inverted in V5 and V6. No cause was evident but this
finding is often a surrogate for pathological T wave inversion in an older subject.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-12
11. 47-year-old asymptomatic ATPL-holder who demonstrates frequent junctional premature
complexes, conducted with minor aberration (incomplete right bundle branch block) due to
prematurity. At slow heart rates the right bundle has a slightly longer ERF1 than the left bundle
and with prematurity, delay in the former may be expected. Atrial prematurity can be premonitory
of atrial fibrillation and a history of excess alcohol intake is not uncommon. It was absent in this
case, and together with normal echocardiogram and normal exercise electrocardiogram, a fit
assessment with annual follow-up was given. The downsloping ST segment in SIII is anormal
variant in this case as the QRST angle is not wide (+400)
1 ERF – Effective refractory period
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-13
12. 56-year-old ATPL-holder who is in atrial fibrillation. The voltages are low. The dominant
negativity of the inferior leads reflects a probable co-existent left anterior fascicular block
(hemiblock), although an inferior myocardial infarction needs to be excluded. Although always
asymptomatic, this pilot initially developed paroxysmal atrial fibrillation which became persistent
and then permanent1. His echocardiogram and exercise recording were always normal. Provided
the pilot is asymptomatic and there is no indication for warfarin (i.e. there is no associated cardiac
abnormality, hypertension, diabetes, history of TIA2 or age >65 years), a fitness assessment with
restriction to multicrew duties may be considered.
1 Paroxysmal: recurrent, intermittent atrial fibrillation that previously terminated without specific therapy.
Paroxysmal atrial fibrillation is self-limited. Persistent: recurrent, sustained atrial fibrillation that was previously
terminated by therapeutic intervention. Persistent atrial fibrillation may be the first presentation, a culmination of
recurrent episodes of paroxysmal atrial fibrillation or long-standing atrial fibrillation (greater than one year).
Persistent atrial fibrillation is not self-limited, but may be converted to sinus rhythm by medical or electrical
intervention. Permanent: Continuous atrial fibrillation which cannot be converted to normal sinus rhythm by
pharmacologic or electrical conversion techniques.
2 TIA – transient ischaemic attack
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-14
13. 64-year-old PPL-holder who demonstrates sinus rhythm with a heart rate of 74 bpm. The S-waves
are dominant in SII, SIII and aVF, giving a mean frontal QRS-axis of -50º. Clockwise rotation of
the heart is present about its longitudinal axis with S-waves in V5 and V6. This pattern had
developed over 20 years and reflects the gradual acquisition of left antero-superior fascicular
block (hemiblock). It is generally a benign condition consistent with fitness to fly. If the change is
abrupt, the possibility of anterior myocardial infarction needs to be considered. Follow-up is
required for any evidence of progression consistent with progressive fibrosis of the conducting
tissue. In this case exercise electrocardiography was normal, and a fit assessment was issued.
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Manual of Civil Aviation Medicine 1(109)
