What is the CHA₂DS₂-VASc score for a 66-year-old male with Diabetes Mellitus (DM), Hypertension (HTN), history of stroke, and a cardiac examination revealing an S3 heart sound and distended Jugular Venous Pressure (JVP)?

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CHA₂DS₂-VASc Score Calculation for a 66-Year-Old Male with Multiple Risk Factors

The correct CHA₂DS₂-VASc score for this 66-year-old male with diabetes mellitus, hypertension, smoking history, prior stroke, S3 heart sound, and distended JVP is 6 points.

Score Calculation Breakdown

According to the CHA₂DS₂-VASc scoring system outlined in the American College of Cardiology/American Heart Association guidelines 1, the patient's score is calculated as follows:

Risk Factor Points Present in This Patient
Congestive heart failure 1 Yes (S3 and distended JVP indicate heart failure)
Hypertension 1 Yes
Age ≥75 years 2 No
Diabetes mellitus 1 Yes
Prior Stroke/TIA 2 Yes
Vascular disease 1 No (not explicitly mentioned)
Age 65-74 years 1 Yes (66 years old)
Sex category (female) 1 No (male patient)
TOTAL 6

Clinical Significance of This Score

This CHA₂DS₂-VASc score of 6 places the patient in a high-risk category for thromboembolic events:

  • A score of 6 corresponds to an adjusted annual stroke rate of approximately 9.8% per year without anticoagulation 1
  • According to the 2014 AHA/ACC/HRS guidelines, this patient has a clear indication for oral anticoagulation therapy 1
  • The patient falls into the "high risk" category (>10%/year risk of arterial thromboembolism) according to the American College of Chest Physicians guidelines 1

Important Clinical Considerations

  • The presence of S3 heart sound and distended JVP are clinical indicators of congestive heart failure, which contributes 1 point to the score 1
  • Prior stroke contributes 2 points as it's one of the strongest predictors of future stroke 1
  • The patient's age of 66 years contributes 1 point (age 65-74 years category) 1
  • While the patient is a smoker, smoking alone is not a specific scoring criterion in the CHA₂DS₂-VASc system, though it does increase overall cardiovascular risk

Common Pitfalls in CHA₂DS₂-VASc Scoring

  1. Failing to count heart failure signs: The S3 heart sound and distended JVP are clinical indicators of heart failure, which contributes 1 point 1
  2. Miscounting age points: Age 65-74 contributes 1 point, while age ≥75 would contribute 2 points 1
  3. Overlooking prior stroke: Prior stroke/TIA contributes 2 points, not 1 point 1
  4. Confusing vascular disease: Vascular disease refers specifically to prior myocardial infarction, peripheral artery disease, or aortic plaque, not to risk factors like smoking 1

This CHA₂DS₂-VASc score of 6 indicates that the patient has a very high risk of stroke and would strongly benefit from oral anticoagulation therapy to reduce this risk, with DOACs being preferred over warfarin in eligible patients 2.

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Atrial Flutter Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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