CHA2DS2-VASc Score

Editors-in-Chief: Gregory Lip, MD [mailto:g.y.h.lip@bham.ac.uk] and C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org]

Overview
The CHA2DS2-VASc score [Congestive heart failure, Hypertension, Age ≥75 years (doubled), Diabetes mellitus, Stroke (doubled), Vascular disease, Age 65–74 years, Sex category] predicts clinical risk of stroke and thromboembolism in atrial fibrillation.

The CHA2DS2-VASc score has been recommended in the 2010 European Society of Cardiology (ESC) guidelines which promotes a risk factor based approach to stroke prevention, and de-emphasises the artificial stratification into low/moderate/high risk, given the poor predictive value of these 3 categories.

Indeed, the CHA2DS2-VASc score is more inclusive of 'stroke risk modifier' risk factors and has been validated in several large independent cohorts. Of note, the most recent validation study used nationwide data on 73,538 hospitalized non-anticoagulated patients with AF, whereby in ‘low risk’ subjects (score=0), the rate of thromboembolism per 100 person-years was 1.67 (95%CI 1.47 to 1.89) with CHADS2 and 0.78 (0.58 to 1.04) with the CHA2DS2-VASc score, at 1 year follow-up. Thus, those categorised as ‘low risk’ using the CHA2DS2-VASc score were ‘truly low risk’ for thromboembolism, and the CHA2DS2-VASc score performed better than CHADS2 in identifying these 'low risk' patients. The c-statistics at 10 years follow-up were 0.812 (0.796 to 0.827) with CHADS2 and 0.888 (0.875 to 0.900) with the CHA2DS2-VASc score, respectively - thus, the CHA2DS2-VASc score also performed better than CHADS2 in predicting ‘high risk’ patients.

Anticoagulation based on the CHA2DS2-VASc score
The following treatment strategies are recommended in the table below based on the European Society of Cardiology guidelines:

Assessment of Bleeding Risk with Anticoagulation
The decision to anticoagulate a patient should also be based upon an assessment of the risk of bleeding using a score such as the HAS-BLED score.