CHA₂DS₂-VASc Score Calculation
For this 72-year-old woman with atrial fibrillation, hypertension, and diabetes, the CHA₂DS₂-VASc score is 4 points, placing her at high risk for stroke with an annual thromboembolic event rate of approximately 4.0%, warranting oral anticoagulation therapy. 1
Step-by-Step Score Calculation
The CHA₂DS₂-VASc scoring system assigns points for specific risk factors 1:
Points Awarded for This Patient:
- C (Congestive Heart Failure): 0 points - not mentioned 1
- H (Hypertension): 1 point - patient has hypertension 1
- A₂ (Age ≥75 years): 0 points - patient is 72 years old (does not meet ≥75 threshold) 1
- D (Diabetes mellitus): 1 point - patient has diabetes 1
- S₂ (Prior Stroke/TIA/Thromboembolism): 0 points - not mentioned 1
- V (Vascular disease): 0 points - no history of MI, PAD, or aortic plaque mentioned 1
- A (Age 65-74 years): 1 point - patient is 72 years old 1
- Sc (Sex category - female): 1 point - patient is female 1
Total Score: 4 points
Risk Stratification and Clinical Implications
Annual Stroke Risk
- A CHA₂DS₂-VASc score of 4 corresponds to an adjusted annual stroke rate of 4.0% 1
- The 2024 ESC guidelines now recommend using CHA₂DS₂-VA (removing the sex criterion), which would give this patient a score of 3, still indicating high risk 1
Treatment Recommendation
Oral anticoagulation is definitively recommended for this patient 1:
- The 2024 ACC/AHA/HRS guidelines recommend oral anticoagulation for patients with CHA₂DS₂-VASc scores ≥2 1
- The 2024 ESC guidelines recommend oral anticoagulation for CHA₂DS₂-VA scores ≥2, and should be considered for scores of 1 1
- Direct oral anticoagulants (DOACs) are preferred over warfarin in eligible patients 1
Important Clinical Considerations
Common Pitfalls to Avoid:
- Age scoring: Note that age is scored in two separate categories - 1 point for 65-74 years AND 2 additional points if ≥75 years (not cumulative, but separate thresholds) 1
- Female sex scoring: Women receive 1 point for sex alone, meaning the minimum possible score for any woman is 1 (women cannot achieve a score of 0) 1
- Vascular disease definition: This specifically includes prior MI, peripheral artery disease, or aortic plaque - not just any cardiovascular condition 1
Bleeding Risk Assessment:
- While this patient requires anticoagulation based on stroke risk, concurrent assessment using HAS-BLED score is recommended to identify modifiable bleeding risk factors 1
- A HAS-BLED score ≥3 suggests caution and need for regular review, but should not preclude anticoagulation in the absence of absolute contraindications 1, 2
Evolving Guidelines:
- The 2024 ESC guidelines have moved toward CHA₂DS₂-VA (removing sex as a criterion), recognizing that female sex alone may not independently increase stroke risk in younger women without other risk factors 1
- However, for this 72-year-old patient with multiple risk factors, the treatment recommendation remains unchanged regardless of which scoring system is used 1