CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk

• Recent guidelines emphasize the strong evidence of benefit with anticoagulation and the lack of benefit from antiplatelet treatment.
• There has been recent work suggesting that sex as a risk factor should be removed from CHA₂DS₂-VASc. Please see the Evidence section for more information.

Most guidelines suggest that scores of 0 (men) or 1 (women) do not require treatment; however, all other patients should receive anticoagulation, preferably with a direct oral anticoagulant (unless contraindicated).

• Anticoagulation is not recommended in patients with non-valvular AF and a CHA₂DS₂-VASc score of 0 if male or 1 if female, as these patients had no TE events in the original study.
• Depending on a patient’s preferences and individual risk factors, anticoagulation can be considered for a CHA₂DS₂-VASc score of 1 in males and 2 in females.
• Anticoagulation should be started in patients with a CHA₂DS₂-VASc score of ≥2 if male or ≥3 if female.
• For those patients in whom anticoagulation is considered, bleeding risk scores such as ATRIA can be used to determine the risk for warfarin-associated hemorrhage. However, these should usually be used as a reminder to regularly address reversible risk factors for bleeding, as the risk-benefit ratio of anticoagulation usually remains favorable.
• Carefully consider all the risks and benefits prior to initiating anticoagulation in patients with non-valvular AF.
• Aspirin monotherapy is not supported by current evidence.

Before initiating anticoagulation, assess the patient’s bleeding risk using validated tools (e.g., HAS-BLED) and consider concomitant risk factors for bleeding. Weigh the risks and benefits carefully, and discuss them thoroughly with the patient for shared decision-making.