What is the CHADS2 (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes mellitus, Stroke or transient ischemic attack) score for a patient with atrial fibrillation, congestive heart failure, hypertension, diabetes mellitus, and a history of stroke, presenting with dyspnea, shortness of breath, palpitations, irregular pulse, high jugular venous pressure (JVP), S3 heart sound, bi-basal crackles, tachycardia, and hypoxemia?

CHADS₂ Score Calculation

This patient has a CHADS₂ score of 5 points, placing him at very high risk for stroke with an annual stroke rate of approximately 12.5%.

Score Breakdown

The CHADS₂ scoring system assigns points as follows 1:

• C (Congestive Heart Failure): 1 point - Present (high JVP, S3 heart sound, bi-basal crackles indicate acute decompensated heart failure) 1
• H (Hypertension): 1 point - Present (known hypertensive, current BP 150/90 mmHg) 1
• A (Age ≥75 years): Cannot determine from "[AGE]-year-old" - assign 0 or 1 point depending on actual age 1
• D (Diabetes Mellitus): 1 point - Present (known diabetic) 1
• S₂ (Prior Stroke/TIA): 2 points - Present (history of stroke) 1

Risk Stratification

If age <75 years: CHADS₂ score = 5 points

• Annual stroke risk: 12.5% (95% CI 8.2-17.5%) 1

If age ≥75 years: CHADS₂ score = 6 points

• Annual stroke risk: 18.2% (95% CI 10.5-27.4%) 1

Clinical Implications

This patient requires immediate oral anticoagulation with warfarin (target INR 2.0-3.0) given the CHADS₂ score ≥2. 1 The combination of prior stroke (which alone assigns 2 points and mandates anticoagulation) plus multiple additional risk factors creates an extremely high thromboembolic risk 1.

Critical Management Points

• Prior stroke history is the most powerful predictor, warranting anticoagulation regardless of other factors 2
• The acute heart failure presentation (evidenced by high JVP, S3, bi-basal crackles, hypoxemia) requires stabilization before initiating anticoagulation 1
• Blood pressure control is critically important before starting anticoagulation, as intracerebral hemorrhage risk is exquisitely sensitive to BP control 2
• The current tachycardia (HR 144/min) requires rate control as part of acute AF management 1

Treatment Algorithm

1. Immediate: Rate control for AF with HR 144/min, treat acute heart failure 1
2. Within 24-48 hours: Initiate oral anticoagulation once hemodynamically stable and BP controlled 1
3. Target INR 2.0-3.0 with warfarin, or consider direct oral anticoagulants as alternative 1, 3