CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk

id

801

full_title

CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk

short_title

CHA₂DS₂-VASc Score

med_description

Calculates stroke risk for patients with atrial fibrillation.

description

The CHA2DS2-VASc Score for for Atrial Fibrillation Stroke Risk calculates stroke risk for patients with atrial fibrillation, possibly better than the CHADS2 score.

keywords

CHA2D2S-VASC, CHA2D2S-VASC Score, chadsvasc, a-fib stroke risk score, a-fib stroke risk, afib stroke score, cha2d2s score,chads2-vasc score, chads2vasc score, atrial fibrillation stroke risk

complaint

[ "Palpitations", "Shortness of Breath", "Weakness" ]

formula

Addition of the selected points:

evidence

The CHA₂DS₂-VASc Score was constructed as an update to the older CHADS₂ Score and was intended as a simple clinical tool for predicting and stratifying the 1-year TE risk in patients with non-valvular AF. Although the derivation study had some methodological shortcomings (e.g., a significant proportion of patients excluded due to missing outcome data, no consideration given to death as a competing event), the CHA₂DS₂-VASc Score has since been validated in a large number of cohort studies from a wide range of regions. Its overall discrimination is consistently modest, with a c-statistic of around 0.6-0.7 in most studies, which is only marginally higher than that achieved by the CHADS₂ Score. However, the low-risk classification of the CHA₂DS₂-VASc Score has demonstrated remarkable negative predictive values, meaning that those who were deemed low risk truely had an exceedingly low TE risk at 1 year. This was a significant improvement over the CHADS₂ Score and has substantial clinical relevance, as it allows clinicians to reliably identify patients with non-valvular AF who do not require anticoagulation.

As such, the CHA₂DS₂-VASc Score has been established as one of the most extensively validated TE risk scores for non-valvular AF and has been consistently included in subsequent international societal guidelines for the management of AF. The CHA₂DS₂-VASc Score has also been explored as a prognostic marker in other patient groups (e.g., patients without AF with acute ischemic stroke). However, these uses are not clinically common or suggested by societal guidelines, and the main use of the score remains the same as its original purpose.

Since its original publication in 2010, there have been substantial changes in the epidemiology of risk factors and management options for non-valvular AF. One of the more controversial and better-explored areas is the role of sex in the CHA₂DS₂-VASc Score, as multiple studies have shown that removal of sex from the CHA₂DS₂-VASc Score may result in non-inferior or even superior discrimination abilities. This was formally recognized by the 2024 European Society of Cardiology guidelines, which advocated the use of the CHA₂DS₂-VA Score (i.e., with the "sex category" variable removed) over the CHA₂DS₂-VASc Score. This would allow unification of the anticoagulation threshold across sexes (i.e., no anticoagulation for a score of 0, to consider anticoagulation for a score of 1, and start anticoagulation for scores ≥2), with the potential benefit of being more inclusive toward non-binary individuals. A Finnish study by Teppo et al. has shown that the CHA₂DS₂-VA Score performs similarly to the CHA₂DS₂-VASc Score, especially in more recent times. An even more recent British study by Champsi et al. showed that CHA₂DS₂-VA is superior to CHA₂DS₂-VASc in overall discrimination, although the difference was small.

There have also been calls to incorporate other well-known TE risk factors into the CHA₂DS₂-VASc Score, such as cancer.

Overall, while the CHA₂DS₂-VASc Score remains one of the core TE risk prediction tools in patients with non-valvular AF, continual changes in the epidemiology, management, and understanding of AF mean that updates and modifications to the score will likely become increasingly common and relevant.

measurements

[]

information

Interpretation:

From Friberg 2012. Note the paradoxical decrease in risk between 7 and 8 points; this reflects the findings published in the study, but in general, assume increasing risk with higher scores.

refrences

{ "Clinical Practice Guidelines": [ { "href": "https://pubmed.ncbi.nlm.nih.gov/30686041/", "text": "Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR; Peer Review Committee Members. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024 Jan 2;149(1):e1-e156." }, { "href": "https://pubmed.ncbi.nlm.nih.gov/32860505/", "text": "Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D; ESC Scientific Document Group. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024 Aug 30:ehae176." } ], "Manufacturer Website": [], "Original/Primary Reference": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/19762550", "text": "Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010 Feb;137(2):263-72. doi: 10.1378/chest.09-1584. Epub 2009 Sep 17. PubMed PMID: 19762550." } ], "Other References": [ { "href": "https://pubmed.ncbi.nlm.nih.gov/39171253/", "text": "Teppo K, Lip GYH, Airaksinen KEJ, Halminen O, Haukka J, Putaala J, Mustonen P, Linna M, Hartikainen J, Lehto M. Comparing CHA2DS2-VA and CHA2DS2-VASc scores for stroke risk stratification in patients with atrial fibrillation: a temporal trends analysis from the retrospective Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) cohort. Lancet Reg Health Eur. 2024 Jun 10;43:100967." }, { "href": "https://pubmed.ncbi.nlm.nih.gov/35757148/", "text": "Bungo B, Chaudhury P, Arustamyan M, Rikhi R, Hussain M, Collier P, Kanj M, Khorana AA, Mentias A, Moudgil R. Better prediction of stroke in atrial fibrillation with incorporation of cancer in CHA2DS2VASC score: CCHA2DS2VASC score. Int J Cardiol Heart Vasc. 2022 Jun 20;41:101072." }, { "href": "https://pubmed.ncbi.nlm.nih.gov/39217497/", "text": "Champsi A, Mobley AR, Subramanian A, Nirantharakumar K, Wang X, Shukla D, Bunting KV, Molgaard I, Dwight J, Casado Arroyo R, Crijns HJGM, Guasti L, Lettino M, Lumbers RT, Maesen B, Rienstra M, Svennberg E, Țica O, Traykov V, Tzeis S, van Gelder I, Kotecha D. Gender and contemporary risk of adverse events in atrial fibrillation. Eur Heart J. 2024 Sep 1:ehae539" } ], "Outcomes": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/22922413", "text": "Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P; ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012 Nov;33(21):2719-47. doi: 10.1093/eurheartj/ehs253. Epub 2012 Aug 24. Erratum in: Eur Heart J. 2013 Mar;34(10):790. Eur Heart J. 2013 Sep;34(36):2850-1. PubMed PMID: 22922413." } ], "Validation": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/22246443", "text": "Friberg L, Rosenqvist M, Lip GY. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J. 2012 Jun;33(12):1500-10. doi: 10.1093/eurheartj/ehr488. Epub 2012 Jan 13. PubMed PMID: 22246443." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/24759791", "text": "Okumura K, Inoue H, Atarashi H, Yamashita T, Tomita H, Origasa H; J-RHYTHM Registry Investigators.Validation of CHA₂DS₂-VASc and HAS-BLED scores in Japanese patients with nonvalvular atrial fibrillation: an analysis of the J-RHYTHM Registry. Circ J. 2014;78(7):1593-9. Epub 2014 Apr 22." }, { "href": "https://pubmed.ncbi.nlm.nih.gov/25323252/", "text": "Chao TF, Liu CJ, Wang KL, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chen TJ, Lip GY, Chen SA. Using the CHA2DS2-VASc score for refining stroke risk stratification in 'low-risk' Asian patients with atrial fibrillation. J Am Coll Cardiol. 2014 Oct 21;64(16):1658-65." }, { "href": "https://pubmed.ncbi.nlm.nih.gov/21282258/", "text": "Olesen JB, Lip GY, Hansen ML, Hansen PR, Tolstrup JS, Lindhardsen J, Selmer C, Ahlehoff O, Olsen AM, Gislason GH, Torp-Pedersen C. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ. 2011 Jan 31;342:d124." }, { "href": "https://pubmed.ncbi.nlm.nih.gov/28375552/", "text": "van Doorn S, Debray TPA, Kaasenbrood F, Hoes AW, Rutten FH, Moons KGM, Geersing GJ. Predictive performance of the CHA2DS2-VASc rule in atrial fibrillation: a systematic review and meta-analysis. J Thromb Haemost. 2017 Jun;15(6):1065-1077." }, { "href": "https://www.ahajournals.org/doi/full/10.1161/circulationaha.115.016713", "text": "Lip GY, Nielsen PB. Should patients with atrial fibrillation and 1 stroke risk factor (CHA2DS2-VASc score 1 in men, 2 in women) be anticoagulated? Yes: even 1 stroke risk factor confers a real risk of stroke. Circulation 2016; 133: 1498–503." }, { "href": "https://www.ahajournals.org/doi/10.1161/strokeaha.116.013253#:~:text=The%20NICE%20and%20European%20guidelines,males%20or%202%20in%20females).", "text": "Fauchier L, Clementy N, Ivanes F, Angoulvant D, Babuty D, Lip G. Should atrial fibrillation patients with only 1 nongender-related CHA2DS2-VASc risk factor be anticoagulated? Stroke 2016; 47: 1831–36." } ], "Validations": [] }

pearls

• Of the 1577 patients that fulfilled the inclusion criteria, outcome information was missing for 31%, who were excluded from the analysis. These patients could have had TE events, causing them to be lost to follow-up.
• Although the derivation study found no statistically significant difference between the CHA₂DS₂-VASc and CHADS₂ risk stratification schemata in predicting TE events, subsequent validation studies (e.g., Friberg 2012 and Olesen 2011) have found CHA₂DS₂-VASc to be significantly superior to CHADS₂ in performance. CHA₂DS₂-VASc has also demonstrated very high negative predictive values in multiple validation studies.
• None of the included patients were anticoagulated. Those at particularly high risk for a TE event may have been already anticoagulated by their primary care physician, potentially skewing the TE rates.
• A subsequent study identified CAD and smoking as potential additional risk factors for TE. However, that study did not show a statistical difference in the predictive risk stratification abilities of the scores.
• Subsequent research suggests that the only "truly low risk" (i.e., 1-year risk of TE <1%) patients are males with a score of 0, or females with a score of 1, and that the default position should be one of anticoagulation.
• The risks of paroxysmal AF and permanent AF are similar, and anticoagulation decisions should not be based on whether AF is permanent or paroxysmal. 
• For patients with hypertrophic cardiomyopathy or cardiac amyloidosis, the 2024 European Society of Cardiology guidelines do not recommend basing stroke prevention strategies on the CHA₂DS₂-VASc Score.
• Presence of other thrombotic risk factors (e.g., impaired renal function) may adversely impact the performance of this score. Interpretation of this score in such patients should be made with caution and with consideration of individual clinical contexts.

usecase

• One of several risk stratification schemata that can help determine the one-year risk of a thromboembolic (TE) event in a non-anticoagulated patient with non-valvular atrial fibrillation (AF) without any history of valvular surgery.
• Can be used in discussions with patients to facilitate shared decision-making regarding their risk for TE events.

reasons

Facilitates the annual stratification of TE and ischemic stroke risk in patients with non-valvular AF.

next_advice

• Recent guidelines emphasize the strong evidence of benefit with anticoagulation and the lack of benefit from antiplatelet treatment.
• There has been recent work suggesting that sex as a risk factor should be removed from CHA₂DS₂-VASc. Please see the Evidence section for more information.

next_actions

Before initiating anticoagulation, assess the patient’s bleeding risk using validated tools (e.g., HAS-BLED) and consider concomitant risk factors for bleeding. Weigh the risks and benefits carefully, and discuss them thoroughly with the patient for shared decision-making.

next_management

Most guidelines suggest that scores of 0 (men) or 1 (women) do not require treatment; however, all other patients should receive anticoagulation, preferably with a direct oral anticoagulant (unless contraindicated).

• Anticoagulation is not recommended in patients with non-valvular AF and a CHA₂DS₂-VASc score of 0 if male or 1 if female, as these patients had no TE events in the original study.
• Depending on a patient’s preferences and individual risk factors, anticoagulation can be considered for a CHA₂DS₂-VASc score of 1 in males and 2 in females.
• Anticoagulation should be started in patients with a CHA₂DS₂-VASc score of ≥2 if male or ≥3 if female.
• For those patients in whom anticoagulation is considered, bleeding risk scores such as ATRIA can be used to determine the risk for warfarin-associated hemorrhage. However, these should usually be used as a reminder to regularly address reversible risk factors for bleeding, as the risk-benefit ratio of anticoagulation usually remains favorable.
• Carefully consider all the risks and benefits prior to initiating anticoagulation in patients with non-valvular AF.
• Aspirin monotherapy is not supported by current evidence.

diseases

[ "Arrhythmia", "Atrial Fibrillation", "Stroke / Transient Ischemic Attack (TIA)" ]

instructions

published

2022-04-21T20:29:47.424Z

purpose

[ "Prognosis", "Treatment" ]

search_terms

[ "chads", "chads2", "chads2-vasc", "chads2vasc", "stroke risk", "anticoagulation", "atrial fibrillation", "afib" ]

seo

{ "keywords_en": "CHA2D2S-VASC, CHA2D2S-VASC Score, chadsvasc, a-fib stroke risk score, a-fib stroke risk, afib stroke score, cha2d2s score,chads2-vasc score, chads2vasc score, atrial fibrillation stroke risk", "meta_description_en": "The CHA2DS2-VASc Score for for Atrial Fibrillation Stroke Risk calculates stroke risk for patients with atrial fibrillation, possibly better than the CHADS2 score." }

specialty

[ "Cardiology", "Critical Care", "Emergency Medicine", "Family Practice", "Geriatrics", "Hospitalist Medicine", "Internal Medicine", "Neurology", "Primary Care" ]

departments

[ "Cardiac", "Neurologic" ]

tags

[]

version_number

1

versions

[]

related

[ { "calcId": 40, "short_title_en": "CHADS₂ Score", "slug": "chads2-score-atrial-fibrillation-stroke-risk" }, { "calcId": 807, "short_title_en": "HAS-BLED Score", "slug": "has-bled-score-major-bleeding-risk" }, { "calcId": 10583, "short_title_en": "CHA₂DS₂-VA Score", "slug": "cha2ds2-va-score-atrial-fibrillation-stroke-risk" } ]

ismed

true

section

[ "whenToUseViewed", "pearlsPitfallsViewed", "whyUseViewed", "nextStepsViewed", "evidenceViewed" ]

cleaned_departments

[ "cardiology", "neurology" ]

cleaned_use

[ "One of several risk stratification schemata that can help determine the one-year risk of a thromboembolic (TE) event in a non-anticoagulated patient with non-valvular atrial fibrillation (AF) without any history of valvular surgery.", "Can be used in discussions with patients to facilitate shared decision-making regarding their risk for TE events." ]

pub

true