CHA₂DS₂-VASc Score and Stroke Risk Management

Risk Stratification by CHA₂DS₂-VASc Score

The American College of Cardiology recommends direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, dabigatran, or edoxaban over warfarin to reduce stroke risk, morbidity, and mortality in patients with atrial fibrillation and a CHA₂DS₂-VASc score ≥2 1
The CHA₂DS₂-VASc scoring system assigns points as follows: Congestive heart failure or LVEF ≤40%: 1 point, Hypertension: 1 point, Age ≥75 years: 2 points, Diabetes mellitus: 1 point, Prior stroke, TIA, or thromboembolism: 2 points, Vascular disease: 1 point, Age 65-74 years: 1 point, Female sex: 1 point 1, 2, 3, 4, 5
Maximum score: 9 points 1

For patients with a CHA₂DS₂-VASc score ≥2, oral anticoagulation is definitively recommended, as atrial fibrillation increases stroke risk 5-fold, and these strokes are associated with greater disability, recurrence risk, and mortality 1, 2, 5
The American Heart Association, American College of Cardiology, and Heart Rhythm Society state that no therapy, aspirin, or oral anticoagulation may be considered for score = 1, though the evidence supports anticoagulation given the substantial stroke risk 5

Direct Oral Anticoagulants (DOACs) such as dabigatran, rivaroxaban, apixaban, and edoxaban are recommended over warfarin in DOAC-eligible patients (Class I, Level of Evidence A) due to their predictable pharmacodynamics, similar or lower major bleeding rates, and significant reduction in hemorrhagic stroke 1, 4, 5
Warfarin is recommended over DOACs for moderate or severe mitral stenosis and mechanical prosthetic heart valves 1

The HAS-BLED score should be calculated to assess bleeding risk, with points assigned for hypertension, abnormal renal/liver function, stroke history, bleeding tendency, labile INR, elderly age, and drugs or alcohol 1, 2, 4
A HAS-BLED score ≥3 indicates caution is warranted, requiring regular review and correction of modifiable bleeding risk factors, but this does not contraindicate anticoagulation 2, 4