The FAA formalized guidance in the AME Guide addressing the use of Coronary Artery Calcium (CAC) scoring in aeromedical decision-making in January 2026 [1]. While this policy has circulated within aeromedical cardiology discussions for some time, its formal publication in the Guide is relatively recent. Administrative delays slowed its incorporation, but the operational principles behind it have been understood for years.

Now that it is clearly published, pilots need to understand what CAC scoring means — and what it does not mean — for medical certification.

What Is Coronary Artery Calcium Scoring?

Coronary artery calcium scoring is a noninvasive CT-based imaging tool that quantifies calcified plaque in the coronary arteries. The result is expressed as an Agatston score, which correlates with overall atherosclerotic plaque burden.

Extensive peer-reviewed literature demonstrates that CAC scoring significantly improves cardiovascular risk stratification beyond traditional risk factors alone.

Large cohort studies and expert consensus statements have shown:

• CAC provides incremental risk prediction beyond the Framingham Risk Score [2].
• In the MESA cohort, increasing CAC scores were strongly associated with higher rates of major adverse cardiovascular events (MACE) [3].
• A CAC score of zero is associated with very low short-term cardiovascular event rates — often referred to as the “power of zero” [4].
• Contemporary cholesterol management guidelines recognize CAC scoring as a tool for refining risk and guiding preventive therapy [5].

Typical risk associations:

• CAC = 0: Very low near-term event risk
• CAC 1–99: Mild plaque burden, modest risk increase
• CAC 100–399: Moderate plaque burden, substantially increased risk
• CAC ≥400: High risk for coronary events

However — and this is critical — CAC scoring does not diagnose obstructive coronary artery disease. It detects calcified plaque, but it does not determine:

• Whether a stenosis obstructs blood flow
• Whether non-calcified (soft) plaque is present
• Whether myocardial ischemia exists

It is a risk marker, not a replacement for a diagnostic test.

Why the FAA Is Concerned

The FAA’s focus is on risk of incapacitation. Coronary artery disease remains one of the leading causes of sudden cardiac events in the general population.

A high CAC score indicates elevated statistical risk of coronary events [3], [4]. From an aeromedical standpoint, that statistical signal requires clarification:

• Is there obstructive disease?
• Is there flow-limiting narrowing of the blood vessels?
• Is there inducible ischemia?
• If disease exists, has it been adequately treated and stabilized?

The FAA’s approach reflects established aeromedical risk management principles: risk must be quantified and mitigated to an acceptable level based on certificate class.

What Happens If CAC Score Is Elevated?

Pilots scoring greater than 100 need exercise stress testing to determine if their experience ECG changes during strenuous exercise that could indicate the need for further testing. Those applying for 1st or 2nd medical certificates with CAC scores greater than 400 also require cardiac catheterization or specialized CT testing to look for obstructing plaques directly.

If additional evaluation demonstrates no clinically significant coronary artery disease, the pilot may be eligible for medical certification following review of the application by the Aeromedical Certification Division (AMCD). However, the FAA will likely require annual documentation confirming that the pilot remains under appropriate medical care and that the cardiac calcification is being monitored to prevent progression.

If obstructive disease is identified, the case transitions into established FAA protocols for known coronary artery disease [1].

Certification will depend on successful restoration of blood flow to the affected coronary arteries and demonstration of adequate cardiac function on exercise stress testing. For first- or second-class pilots, the FAA will also require direct evaluation of the coronary arteries with cardiac catheterization to confirm that no significant obstructive disease remains.

The underlying concept is that calcium scoring alone does not ground pilots. Unmanaged or high-risk coronary disease does.

The Bigger Picture

The formal inclusion of CAC guidance in the AME Guide provides clarity and consistency [1]. It reduces ambiguity for AMEs and pilots alike. More importantly, CAC scoring is not an enemy of certification — it is an early detection tool.

Coronary artery disease progresses silently. CAC scoring can identify risk long before symptoms occur. Multiple peer-reviewed studies confirm that higher CAC scores correlate with increased cardiovascular mortality and event rates [2]–[4]. Avoiding screening out of fear of certification consequences may prevent early intervention.

A high CAC score does not automatically end a flying career. In many cases, it simply triggers further evaluation. If no significant disease is found, flying continues with monitoring. If disease is identified, early intervention can prevent catastrophic outcomes.

Sometimes it is worth accepting a short period of grounding to optimize your health. Because after all — you can’t fly if you’re dead.

References

[1] Federal Aviation Administration, Guide for Aviation Medical Examiners, Washington, DC: FAA, 2024, p. 475. [Online]. Available: https://www.faa.gov/ame_guide/media/ame_guide.pdf

[2] P. Greenland et al., “Coronary calcium score and cardiovascular risk,” Journal of the American College of Cardiology, vol. 49, no. 3, pp. 378–402, 2007.

[3] R. D. Budoff et al., “Ten-year association of coronary artery calcium with atherosclerotic cardiovascular disease events,” Journal of the American College of Cardiology, vol. 72, no. 10, pp. 1141–1156, 2018.

[4] M. J. Blaha et al., “Association between coronary artery calcium and cardiovascular events: The power of zero,” Circulation, vol. 133, no. 9, pp. 849–858, 2016.

[5] S. M. Grundy et al., “2018 AHA/ACC guideline on the management of blood cholesterol,” Journal of the American College of Cardiology, vol. 73, no. 24, pp. e285–e350, 2019.