The overall trend in risk stratification in atrial fibrillation is going towards a lower threshold to anticoagulate either using VKA or NOAC. What I feel is that with the current technology imaging will not be incorporated due to the vast inter- and intra observer discrepancy. However, biomarkers may become incorporated in the risk stratification, especially after data that have recently been published like the STOP-HF trial. So, CHADSVASC will probably even expand more and will be the mainstay element in deciding who gets anticoagulation.

Hi, CHADSVASc will be the major risk factor score, as implemented in the ESC guidelines. It enables truly low risk patients to be differentiated from those at moderate risk, whereas CHADS2 of 1 has a wide spread of risk.

To my opinion the CHA2DS2VASc will prevail in the assessment of the embolic risk. It is based mainly on clinical and demographic parameters and this makes it easy for everyday use.

CHA2DS2VASc identifies better those with low from moderate risk, avoiding the wide range of risk classification from CHADS2.

Cha2d2-vasc

In all probability, we will soon have two scoring systems. One will be the CHA2DS2 VASc clinical score. I am quite sure that an echocardiographic+clinical score will also be available for centers with the facility. But clinical scoring will not vanish due to restricted availability in several countries.

While going through the medical apps on mobile phone it is interesting to compare the risk assessment given for the same type of patient with the two different scores: hypertensive, diabetic 70 years old. 2 quite different results in terms of yearly risk of stroke.

Cha2ds2vasc includes almost twice more parameters so is supposed to be more accurate....however, in the clinical world, the more complex the risk stratification algorithm is, the less you use it (unless you have a mobile!).

The CHA2DS2VASc score is not only an excellent score for thrombosis but also for mortality, I believe it will continue for quite a while

I think CHA2DA2VASc. Whilst the tools are helpful in clinical practice - they are limited as they do not consider cardiogeriatric factors such as frailty, functional and cognitive decline or the likeliness of the patient to adhere to prescribed therapy. All of which are important factors to consider when making individualised treatment decisions. I also think renal markers will play an important part of assessment in the future. - See my recent review in Vascular Health & Risk Management on the limitations of such risk assessment models.

http://www.dovepress.com/atrial-fibrillation-and-thromboprophylaxis-in-heart-failure-the-need-f-peer-reviewed-article-VHRM

Further, there is a need for patient centered approaches to risk assessment of stroke and bleeding risk.

Chad2ds2vas

Of course CHADSVASc. The problem is implementation of those scores in the general population (of AF patients). At least in Poland this is the problem and AF registries show that neither CHADS nor CHADSVASc score influence anticoagulant treatment.

Chad2ds2vas

I think ESC is recommending CHADS VASC and since we are supposed to be applying the recognised international guidelines...what would be interesting is recording both and undertaking a longitudinal study on mortality and morbidity on this- is it possible with national registeries for AF?

Clinical scores have been exploded in the last years. A cardiologic patient can be scored by several differnt types of clinical scores (e.g. GRACE, CHADS2,CHADS2VASC2, CRUSADE, SYNTAX, EUROSCORE, HAS-BLED ............) I am really fed up with medical letters written in style like : Patient with a soandso score of ... and soanssoscore of ..... but a score of .....

The main message behind these above mentioned scores(CHADS2 and CHADS2VASC2) is that only male patients

Neither, it is whatever HHS and my malpractice lawyer feel is the correct thing to do

When the efficacy and safety of the new oral anticoagulants can consistently be demonstrated in both clinical trials and real world, what we really need is a simple tool to help us identify those with true low risk who do not need anti-coagulation. To this end, CHADS2VASC2 will prevail for some time.

I guess none of them. On the other hand, few more years and we will have some betterr understanding on what is behind mispacing/spoontaneous contractions, etc... What is being currently looked for is mishandling Ca in pacemaker cells and cardiac muscle cells (Ca overload, RyRC mutations, etc...) What I would also add is cardiac and/or vascular NOS functioning/dysfunctioning.

Chad2ds2vas

I am agreed. CHA2DS2-VASc may identify those patients with truly low risk.. When we see a patients in clinicial practice we should ask who will not benefit to be under OAC. And CHA2DS2-VASc is the best one to identify these patients.

Of course, the risk scales may give us more information: risk of death, cardiovascular events, major bleeds. In this setting, we are looking forward for a most accuate risk score.

Hy Rui. I believe in scores. They simplified our life. I believe in CHADS-VASc. It is important the stratification of thromboembolic risk and CHADS-VASc is better than other. However it will be very difficult to find a single method for all patients with AF. This is so inhomogenous poulation.

I prefer CHADSVASC, but I agree with Mariana Floria. Scores and guidelines are very important and useful, but obviously not applicable for all patients

CHADSVASC improves slightly the predictive value of CHADS2 to predict embolic events. However, it includes a parameter, atherosclerosis, that may be also a cause of embolism. So, it is not surprising its better predictive value. On the other hand, we have not evidence supporting that CHADSVASC is better than CHADS2 in order to improve the decision-making about anticoagulation yes/not. Both scores have a limited predictive value. We need new scores probably including imaging and biological markers.

Completely agreed with Dr. Josep Alegret. Very interesting point of view.

Although, the real advantage of CHA2DS2-VASc score is to exclude those patients who will not benefit to be under oral anticoagualtion.

I use it a lot in my practice but it is far from perfect now

Regardless of the score being used, there are two oversights that I've seen take place in clinical practice: (1) scoring system is used incorrectly and generates an inaccurately low risk due to patient having valvular heart disease or even a prosthetic valve and (2) over look that the score is an annualized estimate so that we sometimes prefer the Framingham scoring to get a 5 yr or 10 yr risk projection rather than a one-year estimate.

I vote for CHA2DS2VASc

Here, in some aspects, a newer CHA2DS2-VASc score adds some redundat data. Also, usefulness of scores cannot be sconsidered in separation from the HASBLED, a score for heamorrhagic risk assessment. Truly, data indicates that the higher thrombotic risk, the higher the heamorrhagic risk. Thus, some parameters of the scores are actually overlapping. Indeed, a novel risk score should not use the same parameters that are in use in HASBLED score. If the age is considered, biological rather than chronologic age should be in a use. Hypertension as a category should be pointed out only in patients with not sufficiently controlled BP. If a patient with systemic hypertension hasBP values around 120/75 on drugs, I would expect that he/she shold not be signed as hypertensive as a category. Rather, a poor controlled systemic hypertension should be considered. Interstingly, as renal dysfucntion was considered as important for HASBLED score, it was ignored in the CHADSVASC. SO, why the use of the novel oral anticoagulant drugs dose and administration is dependent on renal function?

In conlcusion, any scores (at this context) should incllude factors that exactly increase stroke probability in AF patients other than age (both heamorraghic and ischemic store incidence increases), hypertension (both heamorraghic and ischemic store incidence increases), and previous stroke (both heamorraghic and ischemic store incidence increases), renal dysfunction (both heamorraghic and ischemic store incidence increases).

I do believe that detaliled evaluations of a coagulation state, cardiac anatomy (TEE) might offer more than simplified scores. Left atria and ventiriculat enlargment make a patient more prone to ischemic stoke, irrespective of an advanced age and hypertension (2 points in the CHA2DS2-VASc score. Thus, a simple score that balanice both ischemic (thrombosis-rependent) and haemorrhagic strokes will indeed be helpful. Nowadays, risk score are too complex and and too simplified. Age might not be a risk if the other factors are well controlled. Gender if fact does not play a role. Diabetes has been ignored.

So , as CHADS or CHADSVASC might be cenosiderd as recommended, several important factors are missed or under appreciated. Truly, one has to subtract figures from CHADSVASC and HASBLED to be sure that a benefit can be obtained.

A am still awaiting for a reliable score that migh hel to indentify ischemic-stoke risk and heamorrhagic-stroke probabilities. At present, the CHA2DS2-VAS is the only arm of such an evaluation. Rather, a score for a net benefit should be developed.

For the moment, after ESC 2012 we use CHA2DS2VASc score because it includes more variables. However, I would like to see a new validated score which combines stroke prevention AND bleeding risk.

We just published a paper on CHA2DS2VASCc sore and its relation to pulmonary vein isolation (Herz 2013). Interestingly, PVI is equally effective up to a score of 4-5 and is less effective beyond. This a strong implications on pathogensis and relation between afib, underlying substrate and atrial fibrillation.

Dear C Perzanowski

Nice comments. Indeed some clinical factors could be added to risk stratification schemes, but these new variables should demonstrate to add any significant information (adjusting by established risk scales).

In this setting, two recent papers have demonstrated thad chronic kidney disease does not add prognostic information, after adjusting by clinical risk scales (Roldan V et al Thromb Haemost 2013 and Banerjee a et al J Am Coll Cardiol 2013).

I prefer CHA2DS2VASCc sore over CHADS2 but LVEF and LA enlargement should be considered as important as other factors. Mitral valve disease (Mitral stenosis - increase embolic risk and Mitral regurgitation may not important as MS as MR per se reduce spontaneous echo contrast in LA -theoretically...

Sorry but both scores are not applicable in valvular disease. Both risk scores are aplicable in non-valvular AF patients...

The both. My opinion is to use the first one. If the value is 0-1, use the second one.

I agree with https://www.researchgate.net/profile/Marijan_Bosevski/ in his comment

Realy we need to balance between risk of ishemic and heamoragic complication ether we use warfarin or new factor 10 inhibitor

I think we need new scor include new parmter as renal failure history of pervios hamoragic stroke

Also patient on aspirin and Plavix post pci as use dualantiplatlet plus warfarin will over wieght of stroke pervention

Cha2ds2vasc

I believe that CHADS is better that Cha2ds2vasc , because it has been validated in diferent scenarios

Cha2ds2vasc

I agree that scores are always subject to change; I would add that although left atrial volume is an important predictor, nobody seems to know that. Even a 0 value score may not mean really lower risk if the left atrial volume is increased.

Dear Dragos,

If the left atrial volume is increased, there is something underlying: hypertension?, heart failure? or more frequently mitral regurgitation. In the last option, perhaps it is not a non-valvular AF.

Il may not be none, may be only VES, may be constitutional, familial, intensive sport etc.

I think that both wil be used in nest years. But many scores that were used in past, were modified during the years or evn disapear. The medicine change every day!

Taking into account the huge increase in anticoagulation rates due to the use of new drugs - recent preliminary data showed that a significant change occurred in the number of AF pts submitted to anticoagulation after de 1st Cardiology visit -, I believe that the CHADSVASC will be the "one", till results of new risk markers come to our field as solid variables for clinical decision in real life practice.

Dear Colleague,

In reaction to the question asked.

Basede on the three publishedtrials with the so-called NOAC's I would recommend rivaroxaban(Xarelto ) as this compound is tested in the ROCKET AF trial, that is published by Patel et al in the NEJM from 2011. It was tested ( in those days ) with a CHADS2 score ( on average ) of 3.4. The next classification , that is used nowadays is the more refined CHA2DS2VASC score where also the gender of the patient and his/her age > 65 or >75 is taken into account. Thus in the ROCKETY trial rivaroxaban OD was investigated and like was mentioned earlier this compound(As the only NOAC) can be administered Once Daily. That is anadvantage over the other NOAC's like dabigatran and apixaban; these compounds are used twice daily.

The ASC guiddelines for anticoagulation have been updated in August 2012 and this is published in the EHJ August 2012 and the ESC is in favor of the newer agents (rivaroxaban, dabigatran and apixaban) over the good-old VKA's. The ESC is in favor without stating A is better than B.

Therefor I recomend Xarelto(R) OD as this will be beneficial for the patient's compliance in general. Xarelto is an adequate anticaoagulans( in the opinion of the ESC) and so therefore I can recommend this compound.

I think that other scores should be developped as new generations of anti coagulants are developped

I agree that LAvolume may be an important prognostic indicator: CHADS VASC may take into account Marne too Manu classical cardiovascular risk factors and may be not specific enough

CHA2DS2VASc score is the fundamental score for the next years

Two scores are important to AF. But they are not enough. In recent study, you can find a new score emerge: R2CHADS2 score which included CCr < 60 ml/min as 2 point. So, this score may constantly improving in the future. I also believe that this will not too far away.

Scores for risk stratification are important and usefull but they cannot replace the doctors work (anamnesis, clinical, history, further riskfactors not mentioned in the scores). For the final decision how to treat the indivdual patient the score can be only one aspect!

CHADS2 score of 0 does not reliably identify AF patients who are ‘truly low-risk’. Many patients classified as ‘low-risk’ using CHADS2 have stroke rates >1.5%/yr. CHA2DS2VASC is more precise in this setting.

I am convinced that both scores are insufficient and should be validated by individualized approach taking into accont many other parameters. But, simplification is always attractive.

Scores for every kind of disease are equal to guidelines. These are suggestions, recommendations, but they should never replace our good sense.

I found CHADSvasc2 score very nice and easy to remember and to assess risk of stroke in AF patients. I look forward in the next future if we can put a new S in this score.

S like Sleep apnoea syndrome (OSA). OSA has been found to be strongly associated with atrial fibrillation. The mechanisms involved appear to be a combination of large negative intra-thoracic pressures, hypoxaemia, hypercapnia, autonomic system activation, systemic inflammation, hypertension, cardiac structural remodelling and atrial electromechanical remodelling conspire to promote atrial fibrillation.

Keep an eye on Sleep Apnoea syndrome. Especially in young patient where a LONE atrial fibrillation has been diagnosed.

I use CHA2DS2Vasc routinely, and it's simple. But I consider also echocardiographic data in assessing the thromboembolic risk in AF. Very large atrium, spontaneous echo contrast are predictor of thrombosis.

Both scores will certainly last, helping physicians/cardiologists decide whether or not long-term anticoagulation is needed. Imaging techniques, in primis transesophageal echocardiography, but also CTA and CMR will not be able to replace these scores because they provide diferent answers pertaining to the acute management of a patient in atrial fibrillation/flutter. In this setting, their role, which is crucial, is aimed at ascertaining whether or not cloths have already formed in the LAA, before proceding to D/C cardioversion. However, the absence of cloths do not change the future strategy of anticoagulation, if such need has been confirmed by the use of the above mentioned scoring systems. Regarding the differentiation between CHADS2 and CHA2DS2VASc, the first is the one most commonly applied, and generally replaced by the second only in particular low risk cases with CHADS2 of 0 or 1.

I agree

I think that now these scores are an optimal and largely diffuse or easy method to stratify thrombo and cardioembolic risk in AF pts.as HASBLED for hemorragic risk ,to decide of initiating anticoagulant therapy .These scores are based on anamnestic and clinical parameters,don't need neither of Echo neither of laboratory.

In this moment, boths scores are very important for risk stratification of AF, but is impossible to affirm that will be the fundamental score during next years, because the changes in medicine are very fast.

CHA2DS2VASC score is the best option

I agree with previous observations that patients with otherwise normal heart and at low CHADS2 score may have a high incidence of stroke. The reasons are multiple, including incomplete assessment of contributing factors.

I also agree that in some settings, additional information not covered by CHADS2 (or CHAS2DS2VASc) may be important. In hypertrophic cardiomyopathy, for example, both LV outflow gradient and AF presentation form (either paroxysmal or persistent) play key roles in risk stratification for stroke. Patients with carotid or ascending aorta plaques may be at increased risk for stroke as compared to those with plaques only in the abdominal aorta or the lower limbs territory. On the other hand, it is also a consensus that risk scores may simplify the stratification process.

Thus, development of tailored scores focusing on particular environments may represent an optimal approach and a trend to the future of risk stratification approach.

Peace and blessings.

Petrus Buhre, Anticoagulation clinic Star-MDC, Rotterdam, the Netherlands

We treat patients with atrial fibrillation. The prescribing phycisian uses the CHA2DS2VASc-score to consider if the patient needs anticoagulation or not and we use the CHADS2-score to decide whether a patient undergoing surgery needs bridging or not.

I think that both score are useful, the second one is more precise. But what is not routinely assessed is the thrombogenic-fibrinolitic profile of the patient that could be involved in the thrombogenic complication of AF. We have found that PAI-1, rTPA and D-Dimer plasma levels are modified in many pts with AF as well as in pts with carotid plaques. What could be inetresting to investigate is whether this modifications are primarily related to endothelial dysfunction or secondary to pathology and what is the possible relationship with thrombus formation and consequently the embolization risk.

Dear Giuseppe,

I personally think, that at short notrice hardly anything will change regarding biomarkers and echo parameters.

Next to that I think that the CHA2DS2VASc score only will win in attention for risk stratification of AF. So I think that this score will only win in popularity. Also the ESC is using this score atr the moment, but it will be hard to get rid of the "good old" CHADS2score as it took many years that everybody was familiar with this score and I guess that the same will happen fot the CHA2DS2VASc score although it contains more specific information as gender and age is of higher importance.

with kind regards, Hans Eeltink ,medical advisor CV for Bayer b.v. NL.

Dear Hans,

I think that all is useful if appropriately used, but I also think that is very hard to get rid of habits. In any case, unfortunely medicine is not mathematics; hence I think that all we have should be used if it let us to take a step forward, but at the same time I need to be ready to approach new possibilities testing if they might give me new solutions or utilities. Merry Christmas and thanks for replying.

OK Giuseppe,

take care and a merry Christmass to you and your loved ones.

with kind regardfs, Hans

To me, the score is just a tool to assess the stroke risk to due AF. All the CVS risk factors +- the future biomarkers or other new factors have to be considered as a whole. Actually, I sometimes doubt its usefulness as whenever they are more than 1, the risk of stroke is already there and we have to consider anticoagulation anyway. Ultimately, one has to balance the thrombotic risk and the bleeding risk when treatment is started. Probably, the higher the score, esp with those thrombotic biomarkers, the higher the anticoagulated state it needs to be but limited by the bleeding risk. Is the current one dose for all NOAC enough really especially the anticoagulation state in individual patients cannot be monitored?

CHA2DS2VASc is likely to likely to become the standard as the NOACs make it safer and easier to anti coagulate patients, the threshold to start treatment will drop. A more aggressive scoring system is therefore more appropriate.

Also from a personal perspective, if you have chosen not anti coagulate based on a CHADS2 of 0, and the patient goes on to have a stroke, then you will wish you were more aggressive. This has happened to me, so now I do not use CHADS2.

Without doubt CHA2DS2-VASc. More precise for the moment. Do not forget that a CHAS2 = 0 can be a CHA2DS2-VASc for certain patients.

For low risk pts use of chadsvasc is appropriate while for higher risk groups both scores will yield result in the same management recommendation.

For low risk pts use of chadsvasc is appropriate while for higher risk groups both scores will result in the same management recommendation.

Hosen I agree, so for the sake of simplicity and uniformity, the use of CHA2DS2-VASc should be promoted.

The continued used of CHADS2 will result in no anticoagulation (and therefore strokes) in a small number of patients who would otherwise benefit.

Is there any reason to acutely anticoagulate a CHA2DS2vasc =0 patient with atrial fibrillation? This seems to be an area of confusion?

In the ROCKET-AF trial, renal dysfunction was also an independent predictor of stroke in patients with AF. They created the R2CHADS2. The R2CHADS2 model was associated with a C statistic of 0.587 compared with 0.575 for the CHADS2 and 0.578 for the CHA2DS2VASc scores (Circulation. 2013 Jan 15;127(2):224-32)

On pubmed, I cannot find any other studies supporting this data.

CHADS2VASC2 will prevail for some time.

CHA2DS2VASc: using clinical parameters readily available to all professionals and provides a good indication of thromboembolic risk.

I gather from reading recent literature, CHAD2DS2VASc will be more adopted until and unless very reliable biomarkers replace it.

More at risk patients would be identified (and anticoagulated) by using the CHA2DS2VASC score. When the score is zero, you are also more assured that the risk is really low.

Hence, CHA2DS2VASC is the way to go.

In my opinion CHADSSVASC score can stratify much better low risk patients. But i also agree that in the next future others acronims should be added. I m thinking not only in renal failure as was demostrated in ROCKET AF, but also others as the presence of sleep apnea.

2014 AHA/ACC/HRS AF treatment guidelines recommends the following: "'use the CHA2DS2-VASc score rather than the CHADS2 score". So, this is the answer.

CHA2DS2-VASc score has demostrated some advantages over CHADS2 score,so in new 2014 AHA/ACC/HRS AF treatment guidelines CHA2DS2-VASc score is recommended. But may be in future some new items should be added to the score.

2014 AHA/ACC/HRS AF treatment guidelines recommends CHA2DS2-VASc score

ESC 2016 AF Guidelines:

"Patients with a single stroke risk factor (CHA2DS2-VASc score of 2 for women and 1 for men) should be considered for anticoagulation, taking account of individual characteristics and patient preferences (IIaB); men with a CHA2DS2-VASc score of 2 and women with a score of 3 should be recommended for anticoagulation (IA). Non vitamin-K oral anticoagulants (NOACs) are now recommended as the first-line anticoagulant in eligible patients (IA) as a result of their better safety profile."

Almost certainly the most widely utilised and regarded pre-anticoagulation assessment tool.