Coronary Artery Calcium Score Tests
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I do not have any of the six disqualifying cardiovascular conditions listed in 67.311, but I do have an abnormal rhythm issue that I have disclosed for 20 years and have submitted periodic testing for.  I have been flying on a standard Third Class Medical forever.

My latest testing included a “bad” CACS test; however, my cardiologist concluded in view of my stress and echo test results that it was not flow limiting and did not indicate elevated risk.  Nonetheless, the FAA pulled my standard Third Class Medical and granted a special issuance.  The testing they will require for the special issuance is essentially the same testing that would be required if I had any of the six disqualifying conditions, and would be prohibitively expensive (it is not medically necessary so it won't be covered by Medicare).

Almost everyone over a certain age has some coronary artery calcium buildup. l have been unable to find any document explaining how the FAA evaluates CACS testing and what criteria it applies for determining whether any particular level of calcium is disqualifying.

Any insight would be appreciated.

6 Replies
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You did not mention the type of flying you do, however have you considered flying under the BasicMed regulations?  Click on the following link for more information.  

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1590 Posts

@Island Boy At AOPA
And since his most recent medical certificte was issued with an SI for that condition, he's good to go for Basic Med without further FAA medical ado.

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@Daniel Forman
 

I do not have any of the six disqualifying cardiovascular conditions listed in 67.311, but I do have an abnormal rhythm issue that I have disclosed for 20 years and have submitted periodic testing for.  I have been flying on a standard Third Class Medical forever.

My latest testing included a “bad” CACS test; however, my cardiologist concluded in view of my stress and echo test results that it was not flow limiting and did not indicate elevated risk.  Nonetheless, the FAA pulled my standard Third Class Medical and granted a special issuance.  The testing they will require for the special issuance is essentially the same testing that would be required if I had any of the six disqualifying conditions, and would be prohibitively expensive (it is not medically necessary so it won't be covered by Medicare).

Almost everyone over a certain age has some coronary artery calcium buildup. l have been unable to find any document explaining how the FAA evaluates CACS testing and what criteria it applies for determining whether any particular level of calcium is disqualifying.

Any insight would be appreciated.

It is unfortunate you got the test. Coronary artery calcium score does not have much predictive short term value for blockage which is FAA concern. Test is usually positive in diabetics, over age 60, many smokers, and high cholesterol patients who are already high risk for heart attack long term.  Main use is young people on the fence for starting statins or not.  Many cardiologists (myself included) only rarely order this for this reason.  It leads to a lot of testing in asymptomatic patients. You are at increased risk for an event over a long period of time versus a negative test. So FAA is cautious.  Moral for others is limit the amount of testing you get to what is absolutely necessary.  Maybe others can comment on dropping ‘back’ from 3rd class with SI to Basic Med once SI issued.  Interesting solution.  An article if interested.

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@Mark Sanz
Thanks for responding.  There's the regulatory mess and there's the reality of how much risk is indicated by a high CAC score.  I'm concerned with both (I am aware of Basic Med and may end up there but it will be a royal pain recreating my entire medical history instead of just answering most questions PRNC).

Taking the risk issue first:  the paper at the link below asserts that standalone functional stress testing is not very good at assessing risk and argues for using CACS for asymptomatic airmen with heightened risk factors.  If I understand the paper correctly, calcified plaque does not represent heightened risk (as long as it is not flow limiting), but the authors assert that calcified plaque picked up on the CAC score is correlated with non-calcified plaque, which is a threat.  They qualify that, however:  “In those not on secondary prevention, an increasing Agatston Score correlates with increased plaque burden, coronary stenosis and coronary event rates, as shown in table 5.”  So the obvious question is what does the CAC score imply for those who have been on secondary prevention (i.e., statins with well-controlled cholesterol for years)?  The Rumberger paper cited by the authors reviews literature involving asymptomatic subjects but does not indicate whether there are studies that differentiate between subjects based on existing secondary prevention when examining the predictive value of CACS.  Are you aware of any papers that differentiate in this way? 

As for the regulatory mess, 67.311 is limited to 5 specific conditions plus a catch-all in paragraph (c): “Coronary heart disease that has required treatment or, if untreated, that has been symptomatic or clinically significant.”  So the only basis the FAA had for yanking my standard Third Class is if my CAC score equates to clinical significance.  Is there some accepted definition of “clinical significance”?  From a medical (not bureaucratic) point of view, is a high CAC score of “clinical significance”?  If the FAA is using CACS as implying clinical significance, and medically it is not, then I think AOPA should push back.  

FInally, AOPA would do a great service to the pilot population by flagging this issue and suggesting that pilots have a detailed discussion with their docs about the purpose of a CACS test before agreeing to it.  I suggested this in one of my phone calls with the medical folks at AOPA but haven't yet seen any mention of the issue.

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@Daniel Forman
About 5 years ago a friend of mine had  a CACS that was off the charts….. 4400.   Went for all sorts of testing and imaging.  And yes … it was an accurate predictor of problems because just recently he needed to have Coronary Artery Bypass surgery.    

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@Larry Reinstein
 

You are both bringing up good points. No test covers all the boundary conditions just like any FAA Rule.  I was only pointing out that modern medicine is now replete with lots of tests that lead to…. lots of tests :)  

It is one way to search for obstructive coronary disease but not the most effective or accurate in terms of sensitivity and specificity, especially in the patients in earlier post, for the vast majority of people.  CACS look at calcium in the wall of arteries, not blockages.  They are correlated but not identical.

A score of 4400 is astronomical. A private pilot checkride ending in a crash is a pretty good predictor of future problems. Probably not the best way to weed out student pilots who need more training or aren't suited to aviation.  

Mostly I was trying to point out how unnecessary or low accuracy testing may inadvertently affect FAA ratings, as happened to this OP.

All the best