Expansion
Congestive failure, Hypertension, Age, Diabetes, Stroke, Vascular, Age, Sex
Expansion
CHA2DS2-VASc:
- C - Congestive heart failure or left ventricular dysfunction: 1
- H - Hypertension: 1
- A2 - Age 75 or over: 2
- D - Diabetes: 1
- S2 - previous Stroke, TIA or thromboembolism: 2
- V - Vascular disease (previous infarct, peripheral arterial disease, aortic plaque): 1
- A - Age 65 to 74: 1
- Sc - Sex category female: 1
“The two 2s are age 75 and previous stroke.”
Thresholds: anticoagulate if the score is 2 or more in men or 3 or more in women. Consider it at 1 in men. Female sex alone does not warrant anticoagulation.
Bleeding risk is scored separately with ORBIT or HAS-BLED, and a high bleeding score is a prompt to correct modifiable risk factors, not to withhold anticoagulation, since the stroke risk almost always outweighs it.
A direct oral anticoagulant is first line; warfarin is reserved for mechanical valves and moderate to severe mitral stenosis, where the DOACs are inferior. Aspirin is not an acceptable alternative for stroke prevention in atrial fibrillation.