ADD-ONS / SCALES AND SCORES
CHA2DS2-VASc score
David Goldemund M.D.
Updated on 05/11/2023, published on 08/12/2021
Updated on 05/11/2023, published on 08/12/2021
- 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
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CHA2DS2-VASc score and CHADS2 score
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CHA2DS2-VASc
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CHADS2 |
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C – CHF (Congestive Heart Failure) history (EF<40%)
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1
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1 | |
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H – hypertension history
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1
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1 | |
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A – age ≥ 75 years
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2
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1 | |
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D – diabetes history
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1
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1 | |
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S2 – history of stroke/TIA/thromboembolism
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2
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2 | |
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V – history of vascular disease (prior MI, PAD, or aortic/carotid plaque)
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1
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– | |
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A – age 65-74
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1
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– | |
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Sc (sex category)
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1 (female)
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– | |
| CHA2DS2-VASc | CHADS2 |
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Annual stroke risk
[Eckmann,2011] |
Annual stroke risk
Gage, JAMA 2001] |
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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:
- TEE – spontaneous echo contrast or a left atrial thrombus?
- brain CT/MRI – clinically silent infarcts? microbleeds on GRE/SWI?
- assessment of individual bleeding risk (especially intracranial) → Intracranial hemorrhage risk scales
- 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)
