CHA2DS2–VASc score

For other uses, see Chad (disambiguation).
Condition Points
 C   Congestive heart failure
1
 H  Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)
1
 A  Age ≥75 years
1
 D  Diabetes mellitus
1
 S2  Prior Stroke or TIA or Thromboembolism
2

The CHADS2 score is a clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation (AF), a common and serious heart arrhythmia associated with thromboembolic stroke. It is used to determine whether or not treatment is required with anticoagulation therapy or antiplatelet therapy,[1] since AF can cause stasis of blood in the upper heart chambers, leading to the formation of a mural thrombus that can dislodge into the blood flow, reach the brain, cut off supply to the brain, and cause a stroke. A high CHADS2 score corresponds to a greater risk of stroke, while a low CHADS2 score corresponds to a lower risk of stroke. The CHADS2 score is simple and has been validated by many studies.[2]

The CHADS2 score does not include some common stroke risk factors and its various pros/cons have been carefully discussed.[3] The CHADS2 scoring table is shown below:[4] adding together the points that correspond to the conditions that are present results in the CHADS2 score, that is used to estimate stroke risk.

Annual Stroke Risk[2]
CHADS2 Score Stroke Risk % 95% CI
0
1.9
 1.2–3.0
1
2.8
 2.0–3.8
2
4.0
 3.1–5.1
3
5.9
 4.6–7.3
4
8.5
 6.3–11.1
5
12.5
 8.2–17.5
6
18.2
10.5–27.4

CHA2DS2-VASc

To complement the CHADS2 score, by the inclusion of additional 'stroke risk modifier' risk factors, the CHA2DS2-VASc-score has been proposed.[5]

In clinical use, the CHADS2 score has been superseded by the CHA2DS2-VASc score that gives a better stratification of low-risk patients. The CHADS2 score has been outperformed by the CHA2DS2-VASc in multiple patient groups including patients with AF who are receiving outpatient elective electrical cardioversion.[6]

Condition Points
 C   Congestive heart failure (or Left ventricular systolic dysfunction)
1
 H  Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)
1
 A2  Age ≥75 years
2
 D  Diabetes Mellitus
1
 S2  Prior Stroke or TIA or thromboembolism
2
 V  Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque)
1
 A  Age 65–74 years
1
 Sc  Sex category (i.e. female sex)
1

Thus, the CHA2DS2-VASc[7][8][9] score is a refinement of CHADS2[10][11] score and extends the latter by including additional common stroke risk factors, that is, age 65-74, female gender and vascular disease. In the CHA2DS2-VASc score, 'age 75 and above' also has extra weight, with 2 points.

The maximum CHADS2 score is 6, whilst the maximum CHA2DS2-VASc score is 9 (for age, either the patient is ≥75 years and gets two points, is between 65-74 and gets one point, or is under 65 and does not get points).

Annual Stroke Risk[12]
CHA2DS2-VASc Score Stroke Risk % 95% CI
0
0
-
1
1.3
-
2
2.2
-
3
3.2
-
4
4.0
-
5
6.7
-
6
9.8
-
7
9.6
-
8
12.5
-
9
15.2
-

Treatment Guidelines

The CHA2DS2-VASc score has been used in the 2012 European Society of Cardiology guidelines for the management of atrial fibrillation.[13][14][15] The 2014 American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society guidelines also recommend use of the CHA2DS2-VASc score.[16]

The European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guidelines recommend that if the patient has a CHA2DS2-VASc score of 2 and above, oral anticoagulation therapy (OAC) with a Vitamin K Antagonist (VKA, e.g. warfarin with target INR of 2-3) or one of the non-VKA oral anticoagulant drugs (NOACs, e.g. dabigatran, rivaroxaban, edoxaban, or apixaban) is recommended.

If the patient is 'low risk' using the CHADS2 score (that is, 0 in males or 1 in females), no anticoagulant therapy is recommended.

In males with 1 risk factor (that is, a CHA2DS2-VASc score=1), antithrombotic therapy with OAC should be considered, and patient values and preferences should be considered.

Anticoagulation

Treatment recommendations based on the CHA2DS2-VASc score, see ESC guideline are shown in the following table:

Score Risk Anticoagulation Therapy Considerations[13][17]
0 (male) or 1 (female) Low No anticoagulant therapy No anticoagulant therapy
1(male) Moderate Oral anticoagulant should be considered Oral anticoagulant, with well controlled Vitamin K Antagonist (VKA, e.g. warfarin with time in therapeutic range >70%), or a Non-VKA Oral Anticoagulant (NOAC, e.g. dabigatran, rivaroxaban, edoxaban or apixaban)
2 or greater High Oral anticoagulant is recommended Oral anticoagulant, with well controlled Vitamin K Antagonist (VKA, e.g. warfarin with time in therapeutic range >70%), or a Non-VKA Oral Anticoagulant (NOAC, e.g. dabigatran, rivaroxaban, edoxaban or apixaban)

Based on the ESC guidelines on Atrial Fibrillation, oral anticoagulation is recommended or preferred for patients with one or more stroke risk factors (i.e. a CHA2DS2-VASc score of ≥1 in males, or ≥2 in females).[18] This is consistent with a recent decision analysis model showing how the 'tipping point' on the decision to anticoagulate has changed with the availability of the 'safer' NOAC drugs.[15][19]

Those patients recommended for stroke prevention treatment via oral anticoagulation, choice of drug (ie. between a Vitamin K Antagonist and Non-Vitamin K Antagonist Oral Anticoagulant (NOAC)) can be evaluated using the SAMe-TT2R2 score to help decision-making on the most appropriate oral anticoagulant.[20][21]

Bleeding risk

Stroke risk assessment should always include an assessment of bleeding risk. This can be done using validated bleeding risk scores, such as the HEMORR2HAGES or HAS-BLED scores. The latter is recommended in the ESC and Canadian guidelines.[22] If the patient is taking warfarin, then knowledge of INR control is needed to assess the 'labile INR' criterion in HAS-BLED; otherwise for a non-warfarin patient, this scores zero.

References

  1. ↑ Gage BF, van Walraven C, Pearce L; et al. (2004). "Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin". Circulation 110 (16): 2287–92. doi:10.1161/01.CIR.0000145172.55640.93. PMID 15477396.
  2. 1 2 Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ (2001). "Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation". JAMA 285 (22): 2864–70. doi:10.1001/jama.285.22.2864. PMID 11401607.
  3. ↑ Karthikeyan G, Eikelboom JW. The CHADS2 score for stroke risk stratification in atrial fibrillation--friend or foe? Thromb Haemost. 2010 Jul 5;104(1):45-8.
  4. ↑ "Risk of Stroke with AF". VA Palo Alto Medical Center and at Stanford University: the Sportsmedicine Program and the Cardiomyopathy Clinic. Retrieved 2007-09-14.
  5. ↑ 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.
  6. ↑ Yarmohammadi H, Varr BC, Puwanant S, Lieber E, Williams SJ, Klostermann T, Jasper SE, Whitman C, Klein AL. (2012). "Role of CHADS2 score in evaluation of thromboembolic risk and mortality in patients with atrial fibrillation undergoing direct current cardioversion (from the ACUTE Trial Substudy).". Am J Cardiol. 110 (2): 222–6. doi:10.1016/j.amjcard.2012.03.017. PMID 22503581.
  7. ↑ http://www.mdcalc.com/cha2ds2-vasc-score-for-atrial-fibrillation-stroke-risk/
  8. ↑ http://www.saheart.com.au/for-doctors/clinical-tools/cha2ds2-vasc-score.html
  9. ↑ http://www.gpnotebook.co.uk/simplepage.cfm?ID=x20110126111352933383
  10. ↑ http://heart.bmj.com/content/early/2011/11/10/heartjnl-2011-300901.abstract
  11. ↑ http://journal.publications.chestnet.org/article.aspx?articleid=1086288
  12. ↑ "Prevention of stroke in patients with atrial fibrillation: current strategies and future directions". British Medical Journal. Retrieved 30 December 2012.
  13. 1 2 Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P; ESC Committee for Practice Guidelines-CPG; Document Reviewers. 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. Europace. 2012 Oct;14(10):1385-413.
  14. ↑ European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De Caterina R, De Sutter J, Goette A, Gorenek B, Heldal M, Hohloser SH, Kolh P, Le Heuzey JY, Ponikowski P, Rutten FH. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010 Oct;31(19):2369-429.
  15. 1 2 http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/atrial-fibrillation.aspx
  16. ↑ January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014 Dec 2;64(21):e1-76.
  17. ↑ National Clinical Guideline Centre (UK). Atrial Fibrillation: The Management of Atrial Fibrillation. London: National Institute for Health and Care Excellence (UK); 2014 Jun. PubMed PMID 25340239.
  18. ↑ Lip, GY; Lane, DA (19 May 2015). "Stroke prevention in atrial fibrillation: a systematic review.". JAMA 313 (19): 1950–62.
  19. ↑ Eckman MH, Singer DE, Rosand J, Greenberg SM. Moving the tipping point: the decision to anticoagulate patients with atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2011 Jan 1;4(1):14-21.
  20. ↑ Apostolakis S, Sullivan RM, Olshansky B, Lip GY. Factors affecting quality of anticoagulation control among patients with atrial fibrillation on warfarin: the SAMe-TT₂R₂ score. Chest. 2013 Nov;144(5):1555-63.
  21. ↑ Proietti M, Lip G. Simple decision making between a Vitamin K Antagonist and Non-Vitamin K Antagonist Oral Anticoagulant (NOACs): Using the SAMe-TT2R2 Score. European Heart Journal - Cardiovascular Pharmac. http://ehjcvp.oxfordjournals.org/content/ehjcardpharm/early/2015/03/03/ehjcvp.pvv012.full.pdfotherapy
  22. ↑ Cairns JA, Connolly S, McMurtry S, Stephenson M, Talajic M; CCS Atrial Fibrillation Guidelines Committee. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter. Can J Cardiol. 2011 Jan-Feb;27(1):74-90. PMID 21329865.

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