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CHADS2 scoring system

Last edited 3 May 2021. Last reviewed 19 Aug 2023

the long-term risk of stroke in valvular atrial fibrillation (AF) depends on clinical predictors, which are collectively assessed in the CHADS2 scoring scheme, an acronym for Congestive heart failure,hypertension, Age>75, Diabetes mellitus, and prior Stroke (1):

CHADS2 Scoring Scheme

	Condition	Points
C	Congestive heart failure	1
H	Hypertension	1
A	Age > 75 years	1
D	Diabetes Mellitus	1
S2	Prior Stroke or TIA	2

Annual Stroke Risk with Respect to CHADS 2 Score (1)

CHADS2 Score	Stroke Risk %	95% confidence interval
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

Anticoagulation based on the CHADS2 score

Score	Risk	Anticoagulation Therapy	Considerations
0	Low	Aspirin or no treatment	No antithrombotic therapy (or aspirin)
1	Moderate	Aspirin or Warfarin	Aspirin daily or raise INR to 2.0-3.0, depending on factors such as patient preference
2 or greater	Moderate or High	Warfarin	Raise INR to 2.0-3.0, unless contraindicated (e.g. clinically significant GI bleeding, inability to obtain regular INR screening)

To complement the CHADS2 score, by the inclusion of additional 'stroke risk modifier' risk factors, the CHA2DS2-VASc score was developed (2)

these additional 'clinically relevant non-major' stroke risk factors include age 65-74, female gender and vascular disease
in the CHA2DS2-VASc score score, 'age 75 and above' also has extra weight, with 2 points
in clinical use, the CHADS2 score has been superseded by the CHA2DS2-VASc score, which gives a better stratification of low-risk patients

CHA2DS2-VASc score for stroke risk in atrial fibrillation

Feature	Score
Congestive Heart Failure	1
Hypertension	1
Age >75 years	2
Age between 65 and 74 years	1
Stroke/TIA/TE	2
Vascular disease (previous MI, peripheral arterial disease or aortic plaque)	1
Diabetes mellitus	1
Female	1

NICE suggest (3):

use the CHA2DS2-VASc stroke risk score to assess stroke risk in people with any of the following:
- symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation
- atrial flutter
- a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm
do not offer stroke prevention therapy to people aged under 65 years with atrial fibrillation and no risk factors other than their sex (that is, very low risk of stroke equating to a CHA2DS2-VASc score of 0 for men or 1 for women)
anticoagulation may be with apixaban, dabigatran etexilate, rivaroxaban or a vitamin K antagonist
- consider anticoagulation for men a CHA2DS2-VASc score of 1. Take the bleeding risk into account
  - apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options (3)
- offer anticoagulation to people with a CHA2DS2-VASc score of 2 or above, taking bleeding risk into account
  - apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options (3)
- if direct-acting oral anticoagulants are contraindicated, not tolerated or not suitable in people with atrial fibrillation, offer a vitamin K antagonist (3)
- do not offer stroke prevention therapy to people aged under 65 years with atrial fibrillation and no risk factors other than their sex (that is, very low risk of stroke equating to a CHA2DS2-VASc score of 0 for men or 1 for women)
- do not withhold anticoagulation solely because of a person's age or their risk of falls (3)

Reference:

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CHADS2 scoring system

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