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ATTENTION COACH STUDY PARTICIPANTS:

The principal investigators of the study request that you use the official
version of the modified score here.
CHA₂DS₂-VASC SCORE FOR ATRIAL FIBRILLATION STROKE RISK

Calculates stroke risk for patients with atrial fibrillation, possibly better
than the CHADS₂ Score.

When to Use
Pearls/Pitfalls
Why Use

 * 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.

Age


<65
0
65-74
+1
≥75
+2

Sex


Female
+1
Male
0

CHF history


No
0
Yes
+1

Hypertension history


No
0
Yes
+1

Stroke/TIA/thromboembolism history


No
0
Yes
+2

Vascular disease history (prior MI, peripheral artery disease, or aortic plaque)


No
0
Yes
+1

Diabetes history


No
0
Yes
+1


RESULT:

Please fill out required fields.


Next Steps
Evidence
Creator Insights

Dr. Gregory Lip


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 the David A. Price-Evans Chair in Cardiovascular Medicine at
the University of Liverpool and an honorary consultant cardiologist at Liverpool
Heart and Chest Hospital. He is also a researcher in the Aalborg Thrombosis
Research Unit at Aalborg University in Denmark. Dr. Lip is one of the world’s
leading experts in risk stratification of atrial fibrillation, with his research
directly informing the widely-used CHA₂DS₂-Vasc and HAS-BLED Scores.

To view Dr. Gregory Lip's publications, visit PubMed

Content Contributors
 * Calvin Hwang, MD


Related Calcs
 * CHADS₂ Score
 * HAS-BLED Score
 * ATRIA Bleeding Risk


Have feedback about this calculator?
About the Creator
Dr. Gregory Lip


Also from MDCalc...
 * Practice Pearls: Atrial Fibrillation and Stroke Risk
   
   Evidence syntheses and practical tips on management of atrial fibrillation

Related Calcs
 * CHADS₂ Score
 * HAS-BLED Score
 * ATRIA Bleeding Risk


Content Contributors
 * Calvin Hwang, MD





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