What is the CHA2DS2-VASc (Cardiac failure, Hypertension, Age ≥ 75 years, Diabetes, Stroke, Vascular disease, Age 65-74 years, Sex category) score?

From the Guidelines

The CHA2DS2-VASc score is a clinical prediction tool used to estimate the risk of stroke in patients with atrial fibrillation, and it is recommended to use this score to determine the need for anticoagulation therapy, with a score of 2 or higher in males or 3 or higher in females indicating a strong recommendation for anticoagulation 1.

Key Points

• The CHA2DS2-VASc score ranges from 0 to 9, with higher scores indicating greater stroke risk.
• Points are assigned as follows: 1 point each for Congestive heart failure, Hypertension, Age 65-74, Diabetes, and Vascular disease (prior MI, PAD, or aortic plaque); 2 points each for Age ≥75 and prior Stroke/TIA/thromboembolism; and 1 point for female Sex (though this is only counted if other risk factors are present) 1.
• For patients with a score of 0 (males) or 1 (females), anticoagulation is generally not recommended.
• For scores of 1 in males or 2 in females, anticoagulation should be considered, taking into account individual patient characteristics and preferences 1.
• Anticoagulation is strongly recommended for scores of 2 or higher in males or 3 or higher in females, typically with direct oral anticoagulants (DOACs) like apixaban, rivaroxaban, dabigatran, or edoxaban, or with warfarin (target INR 2-3) 1.

Bleeding Risk Assessment

• The HAS-BLED score can be used to assess bleeding risk, with a score of 3 or higher indicating high risk 1.
• Modifiable factors that elevate bleeding risk, such as uncontrolled hypertension, concomitant use of antiplatelet or nonsteroidal agents, and excessive alcohol intake, should be addressed to minimize bleeding risk 1.

Clinical Decision-Making

• The decision to initiate anticoagulation therapy should be based on a patient-centered approach, taking into account individual patient characteristics, preferences, and values 1.
• The CHA2DS2-VASc score should be used in conjunction with clinical judgment and other relevant factors to determine the need for anticoagulation therapy 1.

From the Research

Overview of CHA2DS2-VASc Score

• The CHA2DS2-VASc score is a clinical tool used to predict the risk of stroke in patients with atrial fibrillation (AF) 2, 3, 4, 5, 6.
• The score is calculated based on several factors, including congestive heart failure, hypertension, age, diabetes, stroke or transient ischemic attack, vascular disease, and sex category.

Prediction of Ischemic Stroke

• The CHA2DS2-VASc score has been shown to predict the risk of ischemic stroke in patients with and without AF 2, 5.
• A higher CHA2DS2-VASc score is associated with an increased risk of ischemic stroke, with a modest discrimination ability (C-statistic: 0.67) 5.
• The score has been found to be useful in predicting stroke risk in patients with heart failure, regardless of the presence of AF 2.

Mortality Risk Stratification

• The CHA2DS2-VASc score has been found to stratify mortality risk in patients with and without AF 6.
• A higher CHA2DS2-VASc score is associated with an increased risk of mortality, with a hazard ratio of 1.23 (95% CI: 1.21-1.25) 6.
• The score has been found to be useful in predicting mortality risk in patients with heart failure, regardless of the presence of AF 2.

Anticoagulation Therapy

• The CHA2DS2-VASc score is used to guide anticoagulation therapy in patients with AF 3, 4.
• Anticoagulation therapy has been found to reduce the risk of stroke and mortality in patients with AF, particularly those with high CHA2DS2-VASc scores 3, 4.
• The choice of anticoagulant agent should be made based on the individual patient's risk factors and the benefit-to-risk ratio 3.