A Pilot’s Perspective
Pilots tend to think in terms of checklists, systems, and risk management. We meticulously maintain our aircraft but sometimes overlook the most important engine onboard: our own heart. Coronary artery disease (CAD) remains the leading cause of sudden incapacitation in pilots, and the FAA devotes substantial resources to minimizing that risk.
One of the newer tools in preventive cardiology is coronary artery calcium (CAC) scoring. It’s a quick, non-invasive CT (computerized tomography) scan that looks for calcium deposits in the coronary arteries. For many in the general population, it offers reassurance—or a wake-up call. But what happens when a pilot undergoes this test on their own, outside of medical advice? And what does it mean if the result finds its way into the FAA’s hands?
What is Calcium Scoring?
Calcium scoring uses a specialized CT scanner to detect calcified plaque in the coronary arteries. The result is expressed as an Agatston score, which roughly estimates a person’s coronary plaque burden and their risk of heart attack.
- 0 → No detectable calcium; very low short-term risk.
- 1–99 → Mild plaque; low to moderate risk.
- 100–399 → Moderate plaque; elevated risk of obstructive disease.
- ≥400 → Significant plaque; high risk for clinical CAD and cardiac events.
Unlike coronary CT angiography, calcium scoring does not use contrast and does not visualize soft plaque. It’s essentially a measure of “hard” plaque that has calcified over time.
Why Pilots Consider the Test
Pilots are planners by nature. Some see calcium scoring advertised at their local hospital or through a wellness program and think: Why not get an inside look at my heart health? The test is fast, painless, and costs less than an avionics upgrade.
But while the result may give peace of mind—or raise a red flag—it can also create dilemmas in the aviation medical world.
FAA Reporting Rules: Where Does a Calcium Score Fit?
The FAA requires applicants to disclose:
- All medical conditions
- Visits to healthcare providers in the last 3 years.
- Tests or evaluations that resulted in a diagnosis.
Here’s where the nuance comes in:
- If you get a calcium score entirely on your own (no physician ordered it, no physician reviewed it): You technically have not had a “visit” or a “diagnosis.” At that point, you are not required to disclose the test itself.
- If you show the result to your physician: That is a medical encounter and must be reported on your FAA medical application. If your doctor documents “coronary atherosclerosis” or “coronary artery disease,” that becomes a reportable diagnosis.
- If you bring it to your AME: Your Aviation Medical Examiner is obligated to apply FAA guidance. Depending on your score, they may be able to issue your certificate directly—or they may have to defer your case for FAA review, which can involve stress testing, advanced imaging, or even cardiac catheterization.
The FAA’s Stance
While calcium scoring is not yet written into the regulations, at a recent AME grand rounds, the FAA provided AMEs with internal guidance. In short:
- Low Scores (0–100) → Certificates can be issued without delay.
- Intermediate Scores (101–400) → Usually require Special Issuance.
- High Scores (>400) → Often require further testing: coronary CT angiography (CCTA) or cardiac catheterization before the FAA will consider certification.
This means a pilot who seeks reassurance through testing may inadvertently open the door to greater scrutiny, and in some cases, deferral of their medical certificate.
Beyond the Regulations: The Pilot’s Responsibility
Here’s where flying differs from ordinary medicine. The FAA sets the minimum standard, but each pilot bears a higher responsibility: to fly only when fit.
- A calcium score of 0 is reassuring, but it doesn’t mean you’re immune from heart disease. Lifestyle and routine care still matter.
- A score of 400 is a red flag. Even if you technically meet certification standards, you must ask: Am I safe to fly? Am I willing to bet the lives of my passengers on that answer?
Just as we wouldn’t ignore a cracked cylinder head or a frayed control cable, we shouldn’t ignore warning signs in our own cardiovascular system.
Practical Advice for Pilots
- Think Before You Test
If you’re considering a calcium score, understand the implications—not just medically, but in terms of FAA reporting.
- Be Honest With Yourself
Even if the FAA doesn’t require you to disclose a self-initiated test, you now have information about your own risk. Withholding it might be technically defensible, but does it align with the ethical responsibility?
- Understand The Consequences of Disclosure
- To your doctor: This creates a medical record, which you must report.
- To your AME: This may result in FAA-required follow-up testing.
- To no one: You may avoid regulatory entanglements, but you still bear personal liability if something happens in the cockpit.
- Manage Your Risk Factors
Regardless of your score, you can act on the modifiable risks: blood pressure, cholesterol, diabetes, smoking, diet, and physical activity.
Key Points For Pilots
- A calcium score is a risk marker, not a diagnosis.
- FAA rules hinge on whether the test was linked to a medical encounter or diagnosis.
- Scores above 100 typically require FAA review; scores above 400 may trigger invasive testing.
- Your responsibility as pilot-in-command goes beyond disclosure— it includes honest self-assessment.
Pilot Tips
- Don’t undergo the test casually. Know what you’ll do with the results.
- If you test and your score is elevated, see your physician—even if it complicates certification. Your life is worth more than your certificate.
- Document your exercise tolerance and healthy habits; it strengthens your case for certification if you need Special Issuance.
- Remember: The FAA’s goal is not to ground you, but to keep you and the flying public safe.
Final Thoughts
Calcium scoring can be a powerful tool. For some, it offers peace of mind. For others, it uncovers silent disease. For pilots, it carries additional layers of responsibility and regulation.
At the end of the day, a pilot’s duty is not just to meet FAA minimums, but to safeguard the lives entrusted to them. If a calcium score teaches us anything, it’s this: the heart deserves the same attention as our aircraft.
Fly smart. Fly honest. Fly safe.
