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on either side of the sternum. Lead V4 is placed at the position of the apex of the normal heart – the fifth
inter-costal space in the mid-clavicular line. Lead V3 is placed midway between V2 and V4. Leads V5
and V6 are placed at the same level as V4 in the anterior and mid-axillary lines, respectively (see Figure
1).
Figure 1.— Diagram of the electrode positions of the chest lead used for the
standard 12-lead electrocardiogram. The limb leads are placed on the right and
left arms, and the right and left legs respectively. The right leg is an indifferent
electrode. During exercise the limb leads are positioned on the shoulders and the
iliac crests on each side. This gives a slightly different read out and these
positions should not be used for making standard recordings.
The preferred instrument should record at least three channels simultaneously and be optimally filtered
and damped. On such a machine, the length of a recording is 12 s at the standard speed (25mm/s) and is
presented on a single sheet of A4 paper. Some recording techniques use thermo-sensitive paper which
needs special care when archiving as the recording fades over time. A further 24 s of rhythm strip using
an inferior, anterior and lateral lead such as SII, V1 and V6 should be recorded. If a q wave is present in
SIII, a recording during inspiration should be included. If the q wave is less than 40ms wide and
disappears with inspiration, it is probably innocent. A normal ECG is illustrated in Appendix 1b, ECG no.
1.
In Europe, interpretation of the resting ECG is required to be by “specialists acceptable to the JAA
Aeromedical Section” under JAR FCL 3.130 (d) (where the “Aeromedical Section” is part of the
regulatory authority). In the USA scrutiny is by on-line computer with skilled technician/cardiologist
back up. As computer formatting and reporting have become more reliable and widespread, the need for
specialist interpretation of large numbers of mainly normal ECGs is questionable. Nevertheless, an
experienced interpreter is likely to be more sensitive and more accurate than a computer working to a
preset profile, perhaps for no reason other than he or she can better factor in experience and probability
bias. None of the presently available commercial programmes are approved for the task in the context of
aviation. In practice, although the computer programmes tend to err on the side of caution, i.e. they overreport
(as may scrutinizers due to fatigue or lack of experience). In safety terms, the difference between
ICAO Preliminary Unedited Version — October 2008 III-1-7
computer reporting and reporting by an experienced scrutineer is not likely to be measurable, although
delegation of the responsibility for processing the reports raises issues of process accountability and audit.
For a further exposition on interpretation of the resting ECG see Appendix 1a, and for some ECG
examples in aircrew, see Appendix 1b.
Exercise electrocardiography
There is no requirement for routine exercise ECG in Annex 1. Some airlines require the investigation
either routinely or before employment. When exercise recordings are carried out, often to clarify some
minor ECG anomaly, a standardized protocol such as the Bruce treadmill protocol1 or equivalent should
be employed. The Bruce protocol is not the only one available (Table 1), but it is the most widely used. It
suffers from a shortcoming that it does not present the same challenge to anthropomorphically different
individuals in terms of height and weight.
STAGE (mphB) ruce (%) (mpShh) effiel(d% ) (mpNha)u ghto(n% ) (mphE)l lestad(% )
1
2
3
4
5
6
7
1.7
2.5
3.4
4.2
5.0
5.5
6.0
10.0
12.0
14.0
16.0
18.0
20.0
22.0
1.7
1.7
1.7
2.5
3.4
4.2
5.0
0.0
5.0
10.0
12.0
14.0
16.0
18.0
1.0
2.0
2.0
2.0
2.0
2.0
2.0
0.0
0.0
0.0
3.5
7.0
10.5
14.0
1.7
3.0
4.0
5.0
5.0
6.0
10.0
10.0
10.0
10.0
15.0
15.0
Table 1.— Standard treadmill protocols
The exercise ECG should utilize the 12 standard leads, displaying at least three simultaneously, and be
optimally filtered and damped. The limb leads should be placed on the shoulders and the lower trunk.
Recordings should be made at rest in the erect and lying positions, and after hyperventilation for ten
seconds. A 12-second recording should be made for each of the resting observations, for each minute of
exercise, and for each of 10 minutes of recovery. Not infrequently, diagnostic changes are seen only in the
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Manual of Civil Aviation Medicine 1(72)
