What are the criteria for the CHA₂DS₂-VASc (Congestive heart failure, Hypertension, Age, Diabetes, Stroke, Vascular disease, Age, Sex category) score?

CHA₂DS₂-VASc Score Criteria

The CHA₂DS₂-VASc score consists of 8 clinical components with a maximum total of 9 points, where each letter represents a specific risk factor for stroke in atrial fibrillation patients. 1

Score Components and Point Values

C - Congestive Heart Failure (1 point)

• Symptoms and signs of heart failure regardless of ejection fraction (includes HFpEF, HFmrEF, and HFrEF) 1
• Asymptomatic left ventricular ejection fraction ≤40% 1
• Recent decompensated heart failure or moderate-severe left ventricular systolic impairment on cardiac imaging 1

H - Hypertension (1 point)

• Resting blood pressure >140/90 mmHg on at least two occasions 1
• Current antihypertensive treatment 1
• History of uncontrolled blood pressure 1

A₂ - Age ≥75 Years (2 points)

• Two points assigned because age is a major independent determinant of ischemic stroke risk 1
• Age-related risk exists on a continuum, but ≥75 years receives double weighting 1

D - Diabetes Mellitus (1 point)

• Type 1 or type 2 diabetes as defined by currently accepted criteria 1
• Treatment with glucose-lowering therapy 1
• Fasting glucose ≥126 mg/dL or treatment with hypoglycemic agents 2

S₂ - Prior Stroke/TIA/Arterial Thromboembolism (2 points)

• Previous stroke, transient ischemic attack, or systemic embolism 1
• Confirmed diagnosis of TIA 1
• Any arterial thromboembolism 1
• Weighted 2 points because prior thromboembolism is associated with highly elevated risk of recurrence 1

V - Vascular Disease (1 point)

• Coronary artery disease, including prior myocardial infarction 1
• History of angina 1
• History of coronary revascularization (surgical or percutaneous) 1
• Significant coronary artery disease on angiography or cardiac imaging 1
• Peripheral artery disease 1, 2
• Complex aortic plaque on transesophageal echocardiography 1

A - Age 65-74 Years (1 point)

• One point assigned for age between 65 and 74 years 1
• Indicates moderate increase in stroke risk 2

Sc - Sex Category: Female (1 point)

• Female sex receives 1 point 1
• Critical caveat: Female sex is only relevant as a risk modifier if age >65 or additional associated risk factors are present 1
• Females age <65 with no other risk factors are not at excess stroke risk and should not receive anticoagulation based on sex alone 1

Score Range and Interpretation

The total score ranges from 0 to 9 points, with higher scores indicating progressively greater annual stroke risk. 1, 2

Risk Stratification by Score:

• Score 0 (men) or 1 (women): Truly low risk (0-0.6% annual stroke rate) - anticoagulation not recommended 1, 2
• Score 1 (men): Low-moderate risk (1.3% annual stroke rate) - anticoagulation should be considered 1, 2
• Score ≥2 (men) or ≥3 (women): High risk requiring oral anticoagulation 1, 2

Progressive Annual Stroke Rates:

• Score 2: 2.2% 2
• Score 3: 3.2% 2
• Score 4: 4.0% 2
• Score 5: 6.7% 2
• Score 6: 9.8% 2
• Score 7: 9.6% 2
• Score 8: 6.7% 2
• Score 9: ≥15.2% 2

Clinical Application Algorithm

Step 1: Calculate CHA₂DS₂-VASc score for all patients with newly diagnosed non-valvular atrial fibrillation 2

Step 2: Identify truly low-risk patients (score 0 in men, 1 in women) who do not require antithrombotic therapy 1, 2

Step 3: For all others with score ≥1 (men) or ≥2 (women), offer stroke prevention with oral anticoagulation 1

Step 4: Reassess thromboembolic risk at periodic intervals to ensure anticoagulation is started in appropriate patients 1

Important Clinical Caveats

The 2024 European guidelines now recommend using CHA₂DS₂-VA (without the sex criterion) for clinical decision-making, with oral anticoagulation recommended for scores ≥2 and considered for scores of 1. 1 This represents an evolution away from using female sex as a risk factor.

All patients with atrial fibrillation and hypertrophic cardiomyopathy or cardiac amyloidosis should receive oral anticoagulation regardless of CHA₂DS₂-VASc score. 1

The score has only modest predictive accuracy (C-statistic 0.6-0.7) and does not account for bleeding risk, which must be assessed separately. 2

Stroke risk is dynamic and should be reassessed at every patient contact, as the "delta CHA₂DS₂-VASc score" (change between baseline and follow-up) is the best predictor for ischemic stroke. 1