Commercial and private pilots require an annual risk of an acute incapacitating cardiovascular (CVD) event <1% to maintain their medical certification. OBJECTIVES: (1) to develop a precise, accurate method for estimation of the risk of an acute, incapacitating cardiovascular event, based on a clinical assessment plus blood lipids, glucose determination and ECG; (2) to determine the age at threshold for a range of risk profiles. METHODS: Annual risk of CHD, MI and stroke were determined from recent Framingham regression equations validated for New Zealand. The risk of an acute incapacitating CHD event is bounded by MI risk and CHD risk. Age at threshold was estimated from a weighted combination of Framingham estimates, assuming that 20% of incident angina pectoris is incapacitating. RESULTS: A non-diabetic, non-smoking male with age-specific average Auckland population lipid profile and systolic blood pressure will reach the 1% per annum threshold for an incapacitating cardiovascular event at age 60. Males with 30% lower serum cholesterol and 20 points lower systolic blood pressure will reach the 1% threshold at age 69. Tobacco smoking reduces the age at threshold by 10 years and diabetes by 7 years for males and 12 years for females. The age at threshold is 12 years higher for women versus men with similar modifiable risk factors. A male with several cardiovascular risk factors could reach threshold before age 40. The threshold is 1 to 2 years lower if 50% rather than 20% of new angina is considered to be incapacitating. CONCLUSION: The methodology provides a precise, accurate method for estimation of CVD risk for commercial and private pilots. The new method introduces objectivity and a level playing field for assessment of pilot cardiovascular risk.