BACKGROUND: For over 30 yr the global medical community has attempted to define the acceptable cardiovascular risk in pilots. This challenge is compounded by the ever-changing technological and medical landscape of air travel. We aimed to review the existing literature on estimating the risk of pilot cardiovascular incapacitation and determine if the current guidelines are founded in the best available evidence.METHODS: A detailed review of the guidelines and literature that supports them was completed. Relevant articles were identified by review of the source literature of the guidelines and the references of these source documents. All articles referenced were reviewed in full by both authors. Data that informed the existing recommendations were reviewed and compared to available modern data. The results of these findings were incorporated into a formula that allows for the calculation of acceptable pilot cardiovascular risk given any operator-determined set of variables.RESULTS: Among the evidence that informs current guidelines, there exists a need for further updating. A number of assumptions have been made in creating guidelines and these may no longer reflect the current technological or medical aviation environment. Incorporating the identified variables into a formula allows for the calculation of acceptable cardiovascular risk. This formula was tested using past data and reproduced existing results.DISCUSSION: Current guidelines for pilot cardiovascular risk assessment require review by the international aviation medical community. We propose a novel formula that may serve as a template for future guidelines and may be adapted as aviation technology and health data evolve.Mulloy A, Wielgosz A. Cardiovascular risk assessment in pilots. Aerosp Med Hum Perform. 2019; 90(8):730–734.