CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk
- The CHA2DS2-VASc score is one of several risk stratification schema that can help determine the 1 year risk of a TE event in a non-anticoagulated patient with non-valvular AF.
- The CHA2DS2-VASc score, among other risk stratification schema, can be used to provide an idea of a patient’s risk for TE event.
CHA2DS2-VASc score (Birmingham 2009) was developed after identifying additional stroke risk factors in patients with atrial fibrillation.
- Validation study included 1,084 patients with non-valvular AF, not on anticoagulation, over age 18 with EKG or Holter diagnosed AF in the ambulatory and hospital settings from 182 hospitals in 35 countries from 2003 to 2004 and had known thromboembolic status at 1 year from the Euro Heart Survey database.
- End point used was stroke or other thromboembolic event.
- Used previously developed Birmingham 2009 schema, under the acronym CHA2DS2-VASc.
- Study showed that as CHA2DS2-VASc score increased, rate of thromboembolic event within 1 year in non-anticoagulated patients with non-valvular AF increased as well.
- Considered score of 0 to be low risk for TE events (none seen in cohort at one year), score of 1 intermediate risk (0.6% rate at 1 year), and greater than 1 high risk (3% rate at 1 year).
Points to keep in mind:
- 31% of the patients in their original study group were lost to follow-up at one year and thus were not included in the analysis. These patients could have had thromboembolic events, causing them to be lost to follow-up.
- There was no statistically significant difference found between the CHA2DS2-VASc and CHADS2 risk stratification schema in predicting TE events.
- None of the included patients were anticoagulated. Those at particularly high risk for a TE event may have been already anticoagulated by their PMD, potentially skewing the TE rates.
- A subsequent study examining the performance of CHA2DS2-VASc in predicting TE events on anticoagulated patients also identified CAD and smoking as potential additional risk factors for TE in this subset of patients. However, that study also did not show a statistical difference in the predictive avarious risk stratification abilities of the scores.
Helps with long-term stroke risk stratification for atrial fibrillation patients.
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One recommendation suggests a 0 score is “low” risk and may not require anticoagulation; a 1 score is “low-moderate” risk and should consider antiplatelet or anticoagulation, and score 2 or greater is “moderate-high” risk and should otherwise be an anticoagulation candidate.
- Consider not starting anticoagulation in patients with non-valvular AF and a CHA2DS2-VASc score of 0 as these patients had no TE events in the original study.
- For those patients in whom anticoagulation is considered, risk bleeding scores such as ATRIA can be used to determine the risk for warfarin-associated hemorrhage.
- Carefully consider all the risks and benefits prior to initiating anticoagulation in patients with non-valvular AF.
- Some guidelines suggest that aspirin monotherapy is not supported by evidence.
Addition of the selected points, see below:
Facts & Figures
|Age||<65 years old||0|
|65-74 years old||+1|
|≥ 75 years old||+2|
|Congestive heart failure history||Y/N||+1|
|Stroke / TIA / thromboembolism history||Y/N||+2|
|Vascular disease history||Y/N||+1|
|Diabetes mellitus history||Y/N||+1|
Original/Primary ReferenceLip 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.
ValidationNtaios G, et al. CHADS2, CHA2DS2-VASc, and long-term stroke outcome in patients without atrial fibrillation. March 12, 2013 80:1009-1017; published ahead of print February 13, 2013Friberg 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.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.
OutcomesCamm 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.
From the Creator
Why did you develop the CHA₂DS₂-VASc score? Was there a clinical experience that inspired you to create this tool for clinicians?
The availability of Non-Vitamin K Antagonist Oral Anticoagulants (NOACs, previously referred to as new or novel oral anticoagulants, has led to a major change in the landscape for stroke prevention in atrial fibrillation (AF). Clinicians are also getting better at understanding how to manage warfarin, recognizing the importance of the average time in therapeutic range (TTR). New data are also re-emerging on the poor evidence for the efficacy and safety of aspirin for stroke prevention in AF. The older CHADS2 Score was designed to identify “high risk” patients for warfarin, but many common (and important) stroke risk factors in AF are not included within the CHADS2. CHA₂DS₂-VASc was developed to be more inclusive of common stroke risk factors/modifiers. Numerous validation studies have shown that CHA2DS2-VASc is as good as - or possibly better - than CHADS2 at predicting high risk patients, but CHA2DS2-VASc is certainly best at predicting the “low risk” patients.
What pearls, pitfalls and/or tips do you have for users of the CHA2DS2-VASc score? Are there cases when it has been applied, interpreted, or used inappropriately?
In older guidelines, the focus was to identify AF patients at ‘high risk’ of stroke, to target for warfarin treatment; however, many studies have shown under-use of warfarin amongst such ‘high risk’ patients. In 2014, the AHA/ACC/HRS guidelines recommended used of the CHA2DS2-VASc score as the stroke risk assessment tool of choice.
How best to approach stroke prevention in AF by using the CHA2DS2-VASc score?
In 2012, the European Society of Cardiology (ESC) guidelines recommended a clinical practice shift, to initially focus on the identification of ‘truly low risk’ patients who do not need any antithrombotic therapy. These low risk patients are those CHA2DS2-VASc score of 0 (male) or 1 (female). Subsequently, the next step is to offer effective stroke prevention (ie. Oral anticoagulation) to those with ≥1 additional stroke risk factors.
What recommendations do you have for health care providers once they have the CHA2DS2-VASc score result? Are there any adjustments or updates you would make to the score given recent changes in medicine?
Use the approach recommended in the 2012 ESC or NICE guidelines - first step, identify LOW RISK patients, i.e., CHA₂DS₂-VASc score of 0 (males) or 1 (females), who do not need any antithrombotic therapy, Next or subsequent step is to offer effective stroke prevention to all others with 1 or more additional stroke risk factors. As per the NICE guidelines, aspirin should not be used for stroke prevention in AF - it is minimally effective, not safe nor is it cost effective.
Have you found colleagues adjusting who receives which type of anticoagulant based on the CHA2DS2-VASc score rather than the CHADS2 alone?
Definitely. A CHADS2 of 0 is NOT low risk, and stroke rate can be as high as 3.2%/year if untreated (Olesen et al, Thromb Haemostat 2012). Using CHA₂DS₂-VASc can further refine stroke risk stratification of those with a CHADS2 score of 0 to identify those who would still substantially benefit from oral anticoagulation.
About the Creator
Gregory Lip, MD, is a professor of cardiovascular medicine and director of the Haemostasis Thrombosis & Vascular Biology Unit at University of Birmingham. His major research interest is in the epidemiology of atrial fibrillation (AF), the pathophysiology of thromboembolism in AF and stroke and bleeding risk factors. Dr. Lip practices the full range of cardiovascular medicine at City Hospital, including outpatient clinics, with large atrial fibrillation and hypertension specialist clinics, and coronary care units.
To view Dr. Gregory Lip's publications, visit PubMed