2 July 2026
The UK Civil Aviation Authority has responded to a series of questions from FLYER about its updated cardiovascular guidance for Class 2 medical certificate holders, explaining the medical reasoning behind the changes while leaving several important questions about their practical impact unanswered.
The revised guidance, which introduces the use of the QRISK3 cardiovascular risk calculator as a trigger for further investigation in some pilots, has generated considerable discussion across the General Aviation community.
Many pilots have questioned why the guidance has changed, why a 15% QRISK3 score was chosen, and what the financial and practical implications may be.
In response to readers’ concerns, FLYER submitted a series of questions to the CAA. The Authority’s responses have been attributed to Dr Mike Trudgill, Chief Medical Officer at the CAA.
The CAA was keen to stress that the revised guidance does not represent a change to the regulations governing medical certification.
“The Civil Aviation Authority has updated its cardiovascular guidance to clarify how aeromedical examiners should assess the risk of cardiovascular disease in pilots and air traffic controllers,” it said.
“Importantly, this is not a change in the law. Instead, it is practical, proportionate guidance that enables doctors – and applicants – to make use of screening and diagnostic tools that are now widely available across the UK health sector.”
The Authority added that while some pilots, particularly older applicants, may require further investigation, many others will be able to reduce their cardiovascular risk through lifestyle changes.
One of FLYER’s first questions asked why the guidance was being introduced now, noting that there had been no recent change to ICAO medical standards and no obvious increase in UK recreational aviation accidents attributed to cardiovascular incapacitation.
The CAA replied that the review had not been prompted by ICAO, but by advances in cardiovascular medicine over the past decade.
According to Dr Trudgill, much of the previous guidance was more than ten years old. Since then there have been significant developments in diagnosing and treating cardiovascular disease, together with improved management of risk factors such as cholesterol and diabetes.
The CAA also pointed to changes elsewhere. It said EASA had introduced cardiovascular risk assessment requirements following its Age Study, while the review also considered published medical literature and involved discussions with other aviation authorities including the FAA in the United States, Australia’s CASA and the New Zealand CAA.
The Authority noted that exercise ECGs are becoming less common in clinical practice as cardiologists increasingly use CT coronary angiography (CTCA), and said the revised guidance reflects those developments.
FLYER also asked why a QRISK3 score of 15% had been selected as the trigger for further cardiovascular investigation, and whether the threshold had been derived from aviation-specific evidence or wider NHS practice.
The CAA linked its answer to the long-established aeromedical “1% rule”.
Dr Trudgill explained that QRISK3 is derived from UK population data and is already widely used within the NHS to estimate an individual’s ten-year risk of suffering a cardiovascular event.
Dr Trudgill acknowledged that QRISK3 predicts cardiovascular risk over ten years rather than over the one- or two-year validity of a Class 2 medical, but said modelling had been undertaken to relate it to aviation medical practice.
“Modelling indicates that a 10-year risk of around 15% provides a reasonable approximation to an annualised risk of 1% in the first year after assessment, consistent with the ‘1% rule’ outlined in the ICAO Manual of Civil Aviation Medicine.”
The CAA stressed that QRISK3 is being used to identify pilots who may benefit from more definitive cardiovascular assessment rather than as an automatic barrier to certification.
FLYER asked whether the CAA had estimated how many Class 2 applicants would exceed the 15% threshold and require further investigation.
The Authority did not provide a numerical estimate, but said that “the majority of pilots who continue to hold a Class 2 medical certificate into their 70s are likely to exceed the 15% 10-year cardiovascular risk threshold.”
Pilots with additional cardiovascular risk factors, it said, are likely to reach that threshold earlier, typically during their 60s.
The CAA also released current figures showing there are more than 22,000 valid Class 2 medical certificate holders, of whom 17.5% are aged 60 or over. That’s 3,850 pilots likely to be affected.
FLYER also asked whether the CAA had estimated how many previously undiagnosed cardiovascular conditions would be detected by the new guidance, together with the likely financial impact on pilots requiring further investigation.
The Authority said heart disease remains a leading cause of death in the UK and argued that earlier identification of cardiovascular disease benefits both aviation safety and pilots’ long-term health.
It added that only a small proportion of pilots would ultimately require medical procedures, although stricter management of cardiovascular risk factors would benefit many others.
To illustrate the potential benefit, the CAA cited the case of an apparently healthy 65-year-old private pilot whose further investigation revealed a significant narrowing of a coronary artery. Following treatment, the pilot is expected to return to flying.
On costs, Dr Trudgill acknowledged that the guidance may create a financial burden for some pilots, particularly within General Aviation, but said every effort had been made to minimise unnecessary testing by adopting a risk-based approach and allowing flexibility in the investigations undertaken.
However, the CAA did not provide estimates of the likely overall cost to pilots or the number of clinically significant cardiovascular conditions it expects the new guidance to identify each year.
Finally, FLYER asked how the revised guidance aligned with the CAA’s stated aim of proportionate regulation and avoiding unnecessary burden.
The CAA said the requirement for cardiovascular assessment already exists within UK Aircrew Regulation and associated Acceptable Means of Compliance, but that it had previously been applied with varying degrees of consistency by Aeromedical Examiners.
According to Dr Trudgill, the revised guidance is intended to support “a more consistent and proportionate approach within the existing regulatory framework.”
He also noted that although in-flight cardiovascular incapacitation is uncommon, there have been several recent light aircraft accidents involving older pilots that may have been attributable to acute cardiovascular events, and that concerns raised by both the Air Accidents Investigation Branch and coroners had informed the review.
We welcome the CAA’s willingness to engage with our questions. The objective of improving pilots’ cardiovascular health is one that nobody could reasonably oppose. If earlier investigation identifies pilots with previously undiagnosed heart disease, that has the potential to save lives both in the air and on the ground.
However, while the CAA has explained why it believes cardiovascular risk assessment should evolve, it has been less forthcoming on the expected impact of the policy itself.
The Authority has not estimated how many pilots are likely to require additional investigation, how many clinically significant cardiovascular conditions it expects the new screening process to identify, or the likely financial cost to the General Aviation community.
Those are all reasonable questions whenever a regulator introduces new requirements, particularly where the costs of additional testing will fall on individual pilots.
Similarly, the CAA refers to “several light aircraft accidents” that may have involved cardiovascular incapacitation, together with concerns raised by the AAIB and coroners. Those are potentially important pieces of evidence, but they are not presented here.
Which accidents? What conclusions were reached? What recommendations were made? How many cases were involved? And how did those findings influence the development of this guidance?
If those events formed part of the rationale for the new policy, publishing that evidence would help pilots understand the case for change.
One important point has become clearer as a result of the CAA’s response. The question is no longer whether QRISK3 is a valid predictor of cardiovascular risk — it clearly is, and is widely used throughout the NHS for assessing an individual’s risk of future cardiovascular disease.
Rather, the outstanding question is how a tool designed to predict a person’s ten-year cardiovascular risk in the general population has been translated into an evidence-based trigger for aeromedical investigation and certification decisions.
The CAA has explained that modelling was used to relate a 15% QRISK3 score to the long-established aeromedical “1% rule”, but it has not published that methodology or the assumptions underpinning it.
For a policy that may affect thousands of pilots, greater transparency around that modelling would help pilots, Aeromedical Examiners and the wider aviation community better understand the scientific basis for the new guidance.
Perhaps the biggest unanswered question, however, is how the CAA intends to judge whether this guidance has been successful.
Good regulation should not only have a sound scientific rationale before it is introduced; it should also have clear, measurable outcomes afterwards.
If more pilots undergo additional investigations, what constitutes success? More cardiovascular disease detected? More pilots receiving preventative treatment? Fewer in-flight incapacitations? Fewer fatal accidents? Or simply more consistent decision-making by Aeromedical Examiners?
The CAA has not yet explained how it intends to evaluate the effectiveness of the guidance over time.
That matters because pilots are being asked to accept additional investigations, additional costs and, for some, considerable anxiety. In return, it is entirely reasonable for them to ask what measurable improvement in safety or health the CAA expects to achieve — and, just as importantly, how it will determine whether those objectives have been met.
We suspect this is the beginning rather than the end of the conversation. As more pilots encounter the new guidance during their medical renewals, FLYER will continue to report on its real-world impact, follow the evidence as it emerges, and ask the questions that matter to the General Aviation community.
This is unlikely to be the last word on the subject. If you’re affected by the new guidance during your next Class 2 medical, we’d like to hear about your experience.
Were you asked to undergo additional investigations? What tests were recommended? How long did the process take? Were there significant costs involved? And, perhaps most importantly, do you feel the process was clearly explained and proportionate?
Please email [email protected] . We’ll treat all correspondence in confidence unless you tell us otherwise. Over the coming months we’ll continue to build a picture of how the guidance is working in practice and, where appropriate, put readers’ experiences to the CAA.
The news story above drew on the CAA’s response, here are their words exactly as we received them. Our original questions are in bold.
The Civil Aviation Authority (CAA) has updated its cardiovascular guidance to clarify how aeromedical examiners should assess the risk of cardiovascular disease in pilots and air traffic controllers. Importantly, this is not a change in the law. Instead, it is practical, proportionate guidance that enables doctors – and applicants – to make use of screening and diagnostic tools that are now widely available across the UK health sector.
As with any medical condition, during assessment, consideration will be given to any occupational or flight safety implications, including the risk of sudden incapacitation. For some individuals, particularly as they get older, this may mean further tests are required. However, many others will be able to manage their cardiovascular risk effectively through positive lifestyle changes.
Overall, the updated guidance is designed to support safe, well-informed certification decisions, while encouraging pilots and air traffic controllers to take an active role in maintaining their long-term health.
Q1. We are not aware of any recent change to ICAO medical standards in this area, nor of any significant increase in accidents attributable to cardiovascular incapacitation within UK recreational aviation. What evidence, safety data, medical research or regulatory developments prompted the introduction of this change?
The International Civil Aviation Organization (ICAO) does not set detailed medical standards in this area. It is instead for national licensing authorities. Much of our cardiovascular guidance was produced over 10 years ago. Since then, there have been major developments in the diagnosis and treatment of cardiovascular disease, as well in the modification of risk factors such as high cholesterol and diabetes. Therefore, a comprehensive review of the guidance was needed.
Over the past two years, we have been working with a panel of CAA and external aviation cardiologists to update this material. The process included a review of national clinical guidelines and practice. While exercise ECGs have played an important role in risk assessment, they are increasingly less available as cardiologists switch to more definitive non-invasive imaging techniques such as computed tomography coronary angiography (CTCA). To reflect this, our guidance now has specific criteria for consistent and proportionate interpretation of CTCA findings, based on the extent of coronary disease and its impact on prognosis.
In addition, we took account of evidence published in peer-reviewed medical journals, such as Heart1 , regarding the management of coronary disease in pilots. Relevant regulatory developments have also been considered. Notably, following the publication of its age study in 20192 , the European Union Aviation Safety Agency (EASA) introduced requirements in the EU aircrew regulation for cardiovascular risk assessment from age 40 for both commercial and private pilots. Further, we engaged with other national aviation authorities, including the FAA, CASA and the New Zealand CAA, who are working on similar guidance.
[1] Davenport ED et al. Management of established coronary artery disease in aircrew without myocardial infarction or revascularisation. Heart 2019; 105: s25-s30 2 Simons A et al. Age Limitations Commercial Air Transport Pilots. EASA 2019
Q2. The CAA has adopted a QRISK3 threshold of 15% as a trigger for further cardiovascular investigation. Could the CAA explain the scientific evidence and risk modelling that supports the selection of 15% as the appropriate threshold for private pilots? Was this threshold derived from aviation-specific evidence or from wider cardiovascular risk-management guidance used in the general population?
See answer to Question 3.
Q3. Aviation medical certification has historically been informed by research into pilot incapacitation risk, including the principles underpinning the “1% rule”. QRISK3 predicts the likelihood of a cardiovascular event over a ten-year period. Could the CAA explain how a 15% QRISK3 score was translated into an aviation-relevant assessment of incapacitation risk during the one- or two-year validity period of a Class 2 medical certificate?
Data published by the Office for National Statistics indicates that cardiovascular disease is a leading cause of death among UK males over the age of 60. This is broadly the age at which the annual risk of incapacitation from cardiovascular disease in the general UK male population is about 1% per annum.
QRISK3 is derived from UK population data and is widely used in NHS general practice. It is intended for assessment of individuals without an established diagnosis of cardiovascular disease. QRISK3 uses existing medical, lifestyle and demographic information to estimate the likelihood of a cardiovascular event, such as a heart attack or stroke, which are typically considered to be incapacitating in an aviation context. It is the most appropriate tool for assessing cardiovascular risk in UK pilots, although alternative validated risk scores may be used where clinically justified.
Most cardiovascular risk assessment tools predict outcomes over a 10‑year period. Since cardiovascular risk increases approximately two-fold with each decade of age, risk is not distributed evenly across the period. Specifically, the risk in the first year is lower than if it was a simple linear division, that is, less than one tenth. Modelling indicates that a 10‑year risk of around 15% provides a reasonable approximation to an annualised risk of 1% in the first year after assessment, consistent with the “1% rule” outlined in the ICAO Manual of Civil Aviation Medicine.
We are using QRISK3 and other tools to identify individuals whose level of cardiovascular risk warrants a more definitive assessment, not only for aeromedical certification purposes but also to help pilots maintain their health.
Q4. Prior to introducing the policy, did the CAA estimate:
a. how many Class 2 applicants would exceed the 15% threshold?
The majority of pilots who continue to hold a Class 2 medical certificate into their 70s are likely to exceed the 15% 10‑year cardiovascular risk threshold, reflecting the fact that age is the strongest predictor of risk. Those with adverse cardiovascular risk factors will reach this threshold earlier, typically in their 60s, or, where there are high risk factors, may exceed it at a younger age.
As of January 2026, there were over 22,000 holders of a valid Class 2 medical certificate, with the following distribution:
b. how many previously undiagnosed clinically significant cardiovascular conditions would be identified?
Although heart disease has been declining in the UK , it remains the commonest cause of death for those between the ages of 50 and 79. Tragically, in over half of these cases, the first presentation is sudden death. Early detection of disease is therefore important, not only for flight safety, but to support the long-term health and longevity of those having cardiovascular risk assessment as part of their routine medical examinations.
As a result of cardiovascular risk assessment, only a small proportion of pilots will have conditions identified that require a medical procedure. However, for the majority, it will highlight conditions where action can be taken to reduce the likelihood of having a stroke or heart attack by stricter control of risk factors. As such, these measures will benefit both aviation safety and pilots’ personal health.
The practical impact of cardiovascular risk assessment is illustrated by a personal account from a 65-year-old private pilot. Despite being asymptomatic and having a previously normal resting ECG, after assessment by his AME, he underwent further investigation at his local hospital. He was found to have a significant narrowing in a major coronary artery, conferring a substantial risk of a heart attack. After two successful surgical interventions, this pilot is now expected to return to flying in the coming months. Reflecting on his experience, he regarded his own outcome as compelling evidence of the value of such assessment.
c. the financial impact on pilots required to undergo further investigation?
The CAA recognises that these requirements may place a financial burden on pilots, particularly in the general aviation community, but it is necessary to maintain medical standards in line with advances in medicine. Nevertheless, in developing the guidance for cardiovascular risk assessment, careful consideration has been given to minimising the burden of tests required, with a stratified threshold for further investigation and flexibility in the choice of investigations.
d. If so, could the CAA provide those estimates?
Please see above, a-c
Q5. The CAA’s General Aviation strategy emphasises proportionate regulation and avoiding unnecessary regulatory burden. What assessment was undertaken to determine that the expected safety benefits of this policy outweigh the costs and additional requirements imposed on private pilots?
The pilot population is relatively small, around 50,000 individuals, the majority of whom are considered to be at low risk. Most cardiovascular events occur when pilots are not flying. Nevertheless, although the incidence of in-flight cardiovascular incapacitation is low, in recent years there have been several light aircraft accidents involving older pilots that may be attributable to acute cardiovascular incapacitation. The Air Accidents Investigation Branch (AAIB) has raised concerns, which have been echoed by coroners in Prevention of Future Deaths reports submitted to the CAA.
The UK Aircrew Regulation requires extended cardiovascular assessment when clinically indicated. For Class 2 certification, the associated Acceptable Means of Compliance state that “Applicants with an accumulation of risk factors…should undergo a cardiovascular evaluation by the AeMC or AME”. Previously, this has been undertaken to varying degrees by Air Medical Examiners. The present guidance is therefore intended to support a more consistent and proportionate approach within the existing regulatory framework.
