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 and its updated version, the CHA2DS2-VASc score, are clinical prediction rules for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation (AF), a common and serious heart arrhythmia associated with thromboembolic stroke. Such a score 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 score corresponds to a greater risk of stroke, while a low score corresponds to a lower risk of stroke. The CHADS2 score is simple and has been validated by many studies.[2] In clinical use, the CHADS2 score (pronounced "chads two") has been superseded by the CHA2DS2-VASc score ("chads two vasc"), which gives a better stratification of low-risk patients.

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In clinical use, the CHADS2 score has been superseded by the CHA2DS2-VASc score, which gives a better stratification of low-risk patients.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 CHA2DS2-VASc score (that is, 0 in males or 1 in females), no anticoagulant therapy is recommended.

In males with 1 stroke risk factor (that is, a CHA2DS2-VASc score=1), antithrombotic therapy with OAC may be considered, and people values and preferences should be considered.[17] Even a single stroke risk factor confers excess risk of stroke and mortality, with a positive net clinical benefit for stroke prevention with oral anticoagulation, when compared to no treatment or aspirin.[18] Thromboembolic event rates differ according to various guideline treatment thresholds and methodological approaches.[19]

Anticoagulation

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

Score Risk Anticoagulation Therapy Considerations[13][20]
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).[21] 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, where the threshold for offering stroke prevention (ie. oral anticoagulation) is a stroke rate of approximately 1%/year.[15][22]

Those patients recommended for stroke prevention treatment via oral anticoagulation, choice of drug (i.e. 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.[23][24]

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 HAS-BLED score is recommended in guidelines, to identify the high risk patient for regular review and followup and to address the reversible risk factors for bleeding (e.g. uncontrolled hypertension, labile INRS, excess alcohol use or concomitant aspirin/NSAID use).[20] 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 criterion scores zero. A high HAS-BLED score is not a reason to withhold anticoagulation. Also, when compared to HAS-BLED, other bleeding risk scores that did not consider 'labile INR' would significantly underperform in predicting bleeding on warfarin, and would often inappropriately categorise many patients who sustained bleeds as 'low risk'.[25]

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 (Feb 2010). "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. 137 (2): 263–72. doi:10.1378/chest.09-1584.
  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 (Oct 2012). "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. 14 (10): 1385–413.
  14. ↑ European Heart Rhythm Association, European , 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 (Oct 2010). "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. 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 (Dec 2014). "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. 64 (21): e1–76.
  17. ↑ Joundi, RA; Cipriano, LE; Sposato, LA; Saposnik, G; Stroke Outcomes Research Working, Group (May 2016). "Ischemic Stroke Risk in Patients With Atrial Fibrillation and CHA2DS2-VASc Score of 1: Systematic Review and Meta-Analysis.". Stroke; a journal of cerebral circulation. 47 (5): 1364–7. doi:10.1161/strokeaha.115.012609. PMID 27026630.
  18. ↑ Fauchier, L; Clementy, N; Bisson, A; Ivanes, F; Angoulvant, D; Babuty, D (2016). "Should Atrial Fibrillation Patients With Only 1 Nongender-Related CHA2DS2-VASc Risk Factor Be Anticoagulated?". Stroke. 47: 1831–6. doi:10.1161/STROKEAHA.116.013253. PMID 27231269.
  19. ↑ Nielsen P, Larsen TB, Skjøth F; et al. (2016). "Stroke and thromboembolic event rates in atrial fibrillation according to different guideline treatment thresholds: A nationwide cohort study". Sci Rep. 6: 27410. doi:10.1038/srep27410.
  20. 1 2 National Clinical Guideline Centre (June 2014). "Atrial Fibrillation: The Management of Atrial Fibrillation.". London: National Institute for Health and Care Excellence. PMID 25340239.
  21. ↑ Lip GY, Lane DA (2015). "Stroke prevention in atrial fibrillation: a systematic review". JAMA. 313 (19): 1950–62. doi:10.1001/jama.2015.4369.
  22. ↑ Eckman MH, Singer DE, Rosand J, Greenberg SM (Jan 2011). "Moving the tipping point: the decision to anticoagulate patients with atrial fibrillation". Circ Cardiovasc Qual Outcomes. 4 (1): 14–21. doi:10.1161/circoutcomes.110.958108.
  23. ↑ Apostolakis S, Sullivan RM, Olshansky B, Lip GY (Nov 2013). "Factors affecting quality of anticoagulation control among patients with atrial fibrillation on warfarin: the SAMe-TT₂R₂ score". Chest. 144 (5): 1555–63.
  24. ↑ 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
  25. ↑ Proietti M, Senoo K, Lane DA, Lip GY. Major Bleeding in Patients with Non-Valvular Atrial Fibrillation: Impact of Time in Therapeutic Range on Contemporary Bleeding Risk Scores. Sci Rep. 2016 Apr 12;6:24376. doi:10.1038/srep24376.

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