New rules requiring cardiovascular risk assessment
Cardiovascular Risk Assessment for Pilots and Air Traffic Controllers
From 2026, both the UK CAA and EASA require enhanced cardiovascular risk assessment for pilots and Air Traffic Controllers (ATCOs). The CAA document is here. The purpose is to identify individuals at increased risk of developing coronary artery disease or other cardiovascular conditions that could lead to partial or complete incapacitation through events such as heart attack or stroke.
As cardiovascular risk increases with age, routine assessment becomes a standard part of aeromedical surveillance from the age of 40 onwards. Additional assessment may also be required whenever significant new risk factors are identified, including hypertension, diabetes, elevated cholesterol, chronic kidney disease, sleep apnoea, obesity, HIV, menopause, smoking history, or a strong family history of cardiovascular disease.
Initial Risk Assessment
The first step is calculation of an individual's 10-year cardiovascular risk using a validated scoring tool such as QRISK. This combines age, sex, blood pressure, cholesterol levels, medical history and other relevant factors to estimate the likelihood of a cardiovascular event over the next decade.
Current guidance requires risk assessment at the following intervals:
• Age 40-49: every 5 years
• Age 50-59: every 3 years
• Age 60+: every 2 years
• More frequently where additional risk factors are present
Applicants whose calculated risk exceeds the relevant aeromedical threshold, or who have certain higher-risk medical conditions, will require further specialist cardiology evaluation.
Further Investigation
When additional assessment is required, a cardiologist will undertake a comprehensive cardiovascular review and arrange an appropriate investigation strategy. The aim is not simply to identify disease, but to determine whether an individual's future risk of incapacitation remains within acceptable aeromedical limits and to propose strategies for risk reduction in the future.
Three broad approaches are accepted by the CAA and EASA:
• Exercise Stress ECG (Bruce Protocol)
• Functional Cardiac Imaging (Stress Echocardiography, Stress MRI or Myocardial Perfusion Scanning)
• CT Coronary Angiography (CTCA)
Which Strategy is ‘best’?
Many pilots and ATCOs ask which investigation is most appropriate. The answer largely depends on the individual's priorities, attitude to risk, and the level of diagnostic certainty they wish to achieve.
Exercise Stress ECG
The exercise stress ECG is the traditional aeromedical investigation. It involves exercising on a treadmill while monitoring the ECG, heart rate and blood pressure. It is widely available, relatively inexpensive, does not involve exposure to ionising radiation and remains an accepted assessment pathway under current CAA guidance.
Its main advantage is simplicity and accessibility. However, it is the least sensitive of the approved investigations and is therefore less effective at detecting early or moderate coronary artery disease. A normal stress ECG is reassuring but does not exclude coronary disease with the same certainty as more advanced imaging techniques. Consequently, a negative stress ECG carries a shorter period of validity before repeat assessment is required.
This approach may be attractive for applicants seeking the simplest and lowest-cost investigation while accepting the need for more frequent reassessment. For reference, in our service, the stress ECG component costs £150. We perform this assessment to meet UK CAA, EASA and FAA requirements such as laid out here.
CT Coronary Angiography (CTCA)
CTCA is a modern imaging technique that directly visualises the coronary arteries and allows detection of both obstructive and non-obstructive coronary artery disease. It is significantly more sensitive than a stress ECG and provides detailed information regarding the presence, distribution and overall burden of coronary atherosclerosis.
A normal CTCA offers a very high degree of reassurance and currently has the longest recognised validity period before repeat assessment is required. For many applicants, this reduces the frequency of future investigations and provides the clearest understanding of their cardiovascular status.
Historically, detecting any coronary artery disease could have raised significant aeromedical concerns. However, current CAA policy adopts a more nuanced approach. Rather than focusing solely on whether disease is present, the overall burden and pattern of disease are assessed. This means that many applicants with mild or limited coronary disease may continue flying, whereas those with more extensive or high-risk disease patterns can be identified for treatment and closer follow-up.
For applicants who prefer the highest level of diagnostic accuracy and wish to have the most complete assessment of their coronary health, CTCA is often the preferred investigation. For reference, in our service, the CTCA component costs £490. The CTCA is performed and reported to meet UK CAA specifications here.
Functional Imaging
Functional imaging tests such as stress echocardiography, myocardial perfusion scanning and stress cardiac MRI occupy a middle ground between stress ECG and CTCA. These tests assess whether the heart muscle receives adequate blood supply during exercise or pharmacological stress and provide more information than a standard stress ECG. They are particularly useful in selected clinical situations and remain an accepted option within the aeromedical pathway. For reference, in our service, the functional imaging component costs £800-1000 (depending on the test)
Aeromedical Outcomes
Most applicants undergoing cardiovascular assessment retain their medical certification. Where investigations are normal, no further coronary assessment is typically required until the next scheduled review period. When abnormalities are identified, a detailed specialist assessment allows treatment options, risk reduction measures and certification implications to be considered on an individual basis.
Our Aviation Cardiology Service
We provide comprehensive cardiovascular risk assessments, specialist aviation cardiology consultations, and in house assessment with all of the above listed modalities including stress ECG testing, functional imaging and CTCA, culminating in UK CAA and EASA-compliant aeromedical reporting for pilots and ATCOs. Our goal is to help aviation professionals meet regulatory requirements while obtaining the most appropriate and evidence-based assessment of long-term cardiovascular health.
