What is the management approach for a male patient with hypertension based on the CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes, Stroke or transient ischemic attack, Vascular disease, Age 65-74 years, and Sex category) score?

CHA₂DS₂-VASc Score for a Male Patient with Hypertension

A male patient with hypertension alone receives a CHA₂DS₂-VASc score of 1 point, which places him in an intermediate-risk category where oral anticoagulation should be considered given the annual stroke rate of approximately 1.9-2.75% per year. 1, 2

Score Calculation

For this male patient with hypertension only:

• Hypertension = 1 point (defined as history of hypertension OR current antihypertensive treatment, regardless of current blood pressure control) 1, 2
• Total CHA₂DS₂-VASc score = 1 2

Clinical Significance and Stroke Risk

The annual stroke risk for a male with CHA₂DS₂-VASc score of 1 is NOT truly low:

• Untreated patients with a score of 1 have an annual stroke rate of 1.3-2.75% per year, which exceeds the traditional 1% threshold that justifies anticoagulation 1, 3
• Among males with CHA₂DS₂-VASc = 1, hypertension specifically confers a stroke rate of 1.91% per year 3
• This represents a 3-fold increase in stroke risk compared to patients with a score of 0 (0.49% per year) 4

Management Recommendations

Based on the most recent 2023 ACC/AHA/HRS guidelines, oral anticoagulation should be considered for this patient: 1

Anticoagulation Decision Algorithm:

1. For males with CHA₂DS₂-VASc ≥1, oral anticoagulation is recommended (Class I recommendation) 1, 2

2. Preferred anticoagulant options (in order of preference): 1

   • Direct oral anticoagulants (DOACs) are recommended over warfarin: dabigatran, rivaroxaban, apixaban, or edoxaban 1
   • Warfarin is an alternative if DOACs are contraindicated or unavailable (target INR 2.0-3.0) 1

3. Assess bleeding risk using HAS-BLED score before initiating anticoagulation 2, 5

   • Note: Hypertension in HAS-BLED requires uncontrolled systolic BP >160 mmHg (different criterion than CHA₂DS₂-VASc) 2

Critical Evidence Supporting Treatment at Score = 1:

Recent high-quality data demonstrates that males with CHA₂DS₂-VASc = 1 are NOT low-risk:

• A 2015 Taiwanese nationwide study of 12,935 males with score = 1 showed 14.4% experienced ischemic stroke over 5.2 years (annual rate 2.75%) 3
• A 2024 Danish nationwide study confirmed all CHA₂DS₂-VASc = 1 subgroups had significantly higher thromboembolism rates (1.4-2.3% per year) compared to score = 0 (0.6% per year) 6
• Untreated patients with score = 1 showed a 3.01-fold increase in stroke risk and 3.12-fold increase in mortality at 1-year follow-up 4

Important Clinical Caveats

Do not confuse this with female patients:

• Females with hypertension alone receive 2 points (1 for hypertension + 1 for female sex) and clearly require anticoagulation 2, 7
• The sex point in females does not independently increase risk, but combined with any other risk factor (score ≥2), anticoagulation is definitively indicated 1, 2

Common pitfall to avoid:

• Older guidelines (pre-2019) were ambiguous about treating CHA₂DS₂-VASc = 1, leading some clinicians to withhold anticoagulation 7
• Current 2023 ACC/AHA/HRS guidelines clearly recommend anticoagulation for males with score ≥1 based on accumulated evidence showing substantial stroke risk 1

This patient requires shared decision-making discussion about oral anticoagulation, weighing the 1.9-2.75% annual stroke risk against bleeding risk, with strong consideration for DOAC initiation given the evidence-based mortality and morbidity benefits. 1, 3, 4