ADD-ONS / SCALES AND SCORES

CHA2DS2-VASc score

Created 08/12/2021, last revision 05/11/2023

  • the CHA2DS2-VASc score helps to estimate the annual risk of thromboembolic events in non-anticoagulated patients with non-valvular atrial fibrillation (AFib)
    • patients with paroxysmal atrial fibrillation have a comparable risk of stroke to patients with persistent forms [Hart 2000]
  • the choice of prophylactic medication is guided by the annual stroke risk → for initial risk assessment of thromboembolic complications, the CHA2DS2-VASc score is recommended instead of the older CHADS2 score
    • a significant proportion of patients with a CHADS2 score of 0-1 have a CHA2DS2-VASc score of ≥2 and are thus candidates for anticoagulant therapy  [AFNET register – ESC Congress]
  • low-risk patients, defined by a CHA2DS2-VASc score of 0 (male) or 1 (female), do not require antithrombotic therapy
  • oral anticoagulant therapy is advised for individuals with ≥1 additional stroke risk factor. In secondary stroke prevention, patients score ≥ 2 points and should automatically receive anticoagulant therapy
CHA2DS2-VASc score and CHADS2 score
CHA2DS2-VASc
CHADS2
C – CHF (Congestive Heart Failure) history (EF<40%)
1
1
H – hypertension history
1
1
A – age ≥ 75 years
2
1
D – diabetes history
1
1
S2 – history of stroke/TIA/thromboembolism
2
2
V – history of vascular disease (prior MI, PAD, or aortic/carotid plaque)
1
A – age 65-74
1
Sc (sex category)
1 (female)
CHA2DS2-VASc CHADS2
Annual stroke risk
[Eckmann,2011]
Annual stroke risk
Gage, JAMA 2001]
0 – 0%
1 – 1.35% **
2 – 2.2%
3 – 3.2%
4 – 4.0%
5 – 6.7%
6 – 9.8%
7 – 9.6%
8 – 6.7%
9 – 15.2%
0 – 1.9%
1 – 2.8%
2 – 4.0%
3 – 5.9%
4 – 8.5%
5 – 12.5%
6 – 18.2%

     ** according to some reports, the risk of CHA2DS2-VASc score is lower – 0.2-0.7%   [Friberg, 2015]

  • a limitation common to both scales is the lack of certain critical information:
  • additionally, the scales are based on data from patients on warfarin; a lower bleeding risk can be assumed for those on DOACs

Patients with a HAS-BLED score > 3 and an increased risk of fall

  • patients with a HAS-BLED >3 are at increased risk of bleeding ⇒ careful adjustment of anticoagulant therapy with frequent monitoring is needed
  • the occasionally used lower INR target (1.8-2.5) in elderly patients is not supported by any major studies. Cohort studies show that INR 1.5-2.0 doubles the stroke risk ⇒ INR < 2 is not recommended
  • the risk of major bleeding with adequate anticoagulation therapy is similar to that of antiplatelet therapy in elderly patients ⇒ aspirin should not serve as an alternative to anticoagulation in elderly patients who are eligible for anticoagulant therapy
  • despite the increased risk of falls in the senior population, anticoagulation remains recommended (the benefit of stroke risk reduction outweighs the risk of intracranial bleeding) (Shanah, 2020)
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CHA2DS2-VASc score
link: https://www.stroke-manual.com/cha2ds2-vasc-score/