CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk

• Recent guidelines emphasize the strong evidence of benefit with anticoagulation and the lack of benefit from antiplatelet treatment.
• Studies also suggest that sex may warrant removal from the CHA₂DS₂-VASc score, which forms the basis for the CHA₂DS₂-VA score.

Most guidelines suggest that scores of 0 (men) or 1 (women) do not require anticoagulation; 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.
• Depending on a patient’s preferences and individual risk factors, anticoagulation can be considered for a score of 1 in men and 2 in women.
• Anticoagulation should be started in patients with a CHA₂DS₂-VASc score of ≥2 in men or ≥3 in women.
• For those patients in whom anticoagulation is considered, bleeding risk scores (such as ATRIA bleeding risk score, DOAC score, HAS-BLED score) can be used to determine the risk for warfarin-associated or anticoagulant-associated bleeding. However, these tools should primarily serve as a reminder to regularly address reversible risk factors for bleeding, as the risk-benefit ratio of anticoagulation usually remains favorable.
• In patients with a score ≥2 who have contraindications to oral anticoagulation due to irreversible causes, percutaneous or standalone endoscopic surgical left atrial appendage (LAA) occlusion may be considered. If such patients are undergoing cardiac surgery or endoscopic or hybrid AF ablation, surgical LAA closure may be considered. 
• Clinicians should carefully consider all risks and benefits prior to initiating anticoagulation in patients with non-valvular AF.
• Certain risk factors, such as hypertrophic cardiomyopathy, warrant anticoagulation regardless of the score.
• Aspirin monotherapy is not supported by current evidence.

• 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.