CHA₂DS₂-VASc Score Calculation
For an older male (≥75 years) with a history of stroke but otherwise medically free, the CHA₂DS₂-VASc score is 4 points.
Score Breakdown
The calculation is straightforward based on the 2024 ESC Guidelines 1:
- Age ≥75 years: 2 points 1, 2
- Prior stroke: 2 points 1
- Male sex: 0 points (only females receive 1 point) 1, 2
- No other risk factors present: 0 additional points 1
Total: 4 points
Clinical Significance and Management
This score of 4 places the patient at high risk for recurrent stroke, with an annual stroke rate of approximately 4.0-8.2%. 1, 3, 4
Anticoagulation Recommendation
Oral anticoagulation is strongly recommended (Class I indication) for any patient with a CHA₂DS₂-VASc score ≥2. 1, 2
- Direct oral anticoagulants (DOACs) are preferred over warfarin as first-line therapy, including apixaban, dabigatran, edoxaban, or rivaroxaban 1, 5
- The 2024 ESC Guidelines specifically recommend DOACs due to their 50% reduction in intracranial hemorrhage compared to warfarin 1
- If warfarin is used, maintain INR 2.0-3.0 with time in therapeutic range >70% 1
Important Clinical Caveats
The history of prior stroke alone (2 points) plus age ≥75 years (2 points) creates a particularly high-risk profile that mandates anticoagulation regardless of other factors. 1
- Prior stroke is weighted as 2 points because "previous thromboembolism is associated with highly elevated risk of recurrence" 1
- Even without atrial fibrillation documented, patients with CHA₂DS₂-VASc scores ≥4 have substantial thromboembolic risk 3, 4
- Bleeding risk should be assessed using the HAS-BLED score, but high bleeding risk scores should not be used as a reason to withhold anticoagulation 1
Risk Context
At a CHA₂DS₂-VASc score of 4, the annual stroke risk ranges from 4.0% to 8.2% depending on the presence of atrial fibrillation 1, 3. The absolute benefit of anticoagulation substantially outweighs bleeding risk at this score level 1, 4.