CHADS2 VASc SCOREDR MAHENDRA

CARDIOLOGY,JIPMER

introduction• Atrial fibrillation confers an excess risk of stroke. • stroke risk depends on the presence or absence of various risk factors. • anticoagulant therapy reduces the risk of stroke and all cause mortality. • clinical guidelines recommend stroke thromboprophylaxis among AF pts unless

they are at low risk. • patients with low risk are defined as those with age <65 years and lone AF.

Why Is It Important to Risk Stratify AF Patients?

• current treatment practice for stroke prevention in eligible AF patients revealed ongoing underuse of OAC treatment

• <70% of eligible patients receiving OAC particularly among those patients at highest risk. • high-risk AF patients before admission for stroke revealed that 29% of patients were not receiving any

antithrombotic therapy, • 31% were prescribed antiplatelet therapy, • only about one quarter of the 39% receiving warfarin (10%) achieved therapeutic international normalized ratio

levels. • Overestimation of the risk of bleeding by physicians is a key barrier to OAC prescription.

• a systematic review. Am J Med. 2010; 123: 638–645

• widely used CHADS2 score-• Congestive Heart Failure =1 • Hypertension=1 • Age ≥75 Years=1• Diabetes Mellitus=1• Stroke/TIA =2• scores range from 0 to 6• derived from the risk factors obtained from the original data sets from the AF

Investigators and the Stroke Prevention in AF trial.

Limitation of CHADS2 score• not include many common potential stroke risk factors.• classified as-• score of 0 as low risk • 1–2 as moderate/intermediate risk • ≥ 3 as high risk. • previous stroke or TIA alone as a risk factor categorized as moderate risk using the original

categorization despite this highest risk for subsequent stroke or thromboembolism.• poor predictive value for the CHADS2 schema (c statistics approximately 0.6)• its original validation would categorise nearly 60%– 65% of various AF populations into the

moderate/intermediate risk category. • Physician confusion about use of asprin or warfarin in CHADS2 score 1

How CHADS2VASc score come in picture• 1. new trial data supporting the importance of less well validated risk factors

for stroke• female sex• age of 65 to 74 years• vascular disease• 2. benefit of OAC over aspirin in stroke reduction and mortality, even in patients

at so-called moderate risk (eg, CHADS2 score of 1). • 3. benefit of aspirin for stroke prophylaxis in AF has been questioned.• European Heart Journal (2012) 33, 1500–1510

• The latest (2012) focused update of the ESC Guidelines for the management of AF again recommended the CHA2DS2-VASc score to assess the stroke-risk of non-valvular AF patients (IA), particularly to identify the truly low-stroke-risk patients.

categories of 0 = low risk, 1 = intermediate risk, and ≥ 2 as high risk• CHA2DS2-VASc score to complement the CHADS2 scheme.

• CHA2DS2-VASc scheme tries to formalise female gender, age 65–74, and vascular disease risk factors in an attempt to become more inclusive of common stroke risk factors in AF. • CHA2DS2-VASc is good at identifying truly low risk patients with AF (≤ 1%/year,

with a CHA2DS2- VASc score = 0),• categorised the lowest proportion into the moderate/intermediate risk strata.• point estimate using the c-statistic was marginally better than the CHADS2

schema.

2016 ESC Guidelines for the management of atrial fibrillation 

Stroke prevention therapy in atrial fibrillation patients

conclusion• CHADS2VASc is validated score for estimation of stroke risk.• More useful in differentiating low risk patients.• 0(male),1(female)does not require any anticoagulation therapy.• NOAC is preferred treatment as comparison to VKA.• Combination of anticoagulant and antiplatelet should be avoided.• Aspirin has no role in new European guideline for stroke prevention.• Emerging risk score is ATRIA stroke risk score.

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