Please see the ECG below from a 50 y.o. male who presented for FAA re-certification of his First Class commercial pilots license. He had no complaints at time of exam, or hx of any cardiovascular symptoms.

His re-certification was deferred to the FAA flight surgeon based upon his ECG.  Why?  Hint: It has nothing to do with his left axis deviation or bradycardia.

Answer on next page…….. so NO peaking until you have REALLY thought it through..

I said NO PEAKING!!!

The Big Reveal:

The abnormality was one mm, horizontal ST depression in inferior leads (II, III, AVF) and lateral precordial leads (V5, V6).  Upon failing his certification exam, he had a nucleotide stress test, which he failed, followed closely by an equally miserable cardiac catheterization that lead to a 4 vessel CABG.  He is now back flying again, and I have attached a follow-up ECG from this year that highlights the changes in ST segments in those leads.  This is the same sort of finding you might see on ECG during a stress test.  ST segments normal at rest, and then with stress, one mm or greater flat or down-sloping ST segment depression in more than one lead, and corresponding to a particular arterial distribution (inferior, lateral, anterior).  

There were some good guesses (LAFB is important, and in a small percentage of cases can indicate septal or inferior infarct).  However, his R axis was -42 and usually -45 or greater required for that diagnosis. 

The best guess came from.....Stand up, Holly Barna!! (Oh, wait, she is standing.)

Extra credit for over achievers:  Would you guess that this gentleman has a dominant or non-dominant right coronary artery, and why? Answer to be posted separately.