CHA2DS2-VASc and HASBLED scores is recommended for anticoagulation therapy decision. I would be grateful if any reader would consider the four scenarios that indicate for limitations of the currently recommended scores for thrombotic/bleeding risk in patients with AF.
First, an 81 years normotensive old male with permanent AF. Otherwise, without any other risk factors. Echocardiographic examination revealed a marginal LVH, normal cardiac dimensions including the LA dimension of 38 mm.
Comments: it is enough to be older than 75 years of age to reach 2 points of thrombotic risk score (to be treated with anticoagulants). Meanwhile, the HASBLED score reaches 1 point. The net difference equals the (+) 1 point.
Second, an 81 years old hypertensive male with permanent AF. Otherwise, without other risk factors. Echocardiographic examination revealed a huge LVH due to the aortic stenosis, small cardiac dimensions, and a large LA dimension of 50 mm.
Comments: it is enough to be a hypertensive, older than 75 years of age with hypertension to reach 3 points of thrombotic risk score (to be treated with anticoagulants). Meanwhile, the HASBLED score reaches 2 points. The net difference equals the (+) 1 point.
Third, a 48 years old mild hypertensive female with persistent AF who suffered from diabetes. Echocardiographic examination showed normal cardiac dimensions including the LAD dimension of 33 mm.
Comments: her only risk factors are female gender and diabetes. It is enough to reach 2 points of the CHA2DS2-VASC score (to be treated with anticoagulants). Meanwhile, the HASBLED score reaches 0 point. The net difference equals the (+) 2 points.
Fourth, a 48 years old normotensive female with permanent AF suffered from non-ischemic congestive heart failure with enlarged (echocardiographically determined) cardiac dimensions (LVEDD of 70 mm, LAD of 52mm).
Comments: her only risk factors are female gender and CHF. It is enough to reach 2 points of the CHA2DS2-VASC score (to be treated with anticoagulants). Meanwhile, the HASBLED score reaches 0 point. The net difference equals the (+) 2 points.
Please provide the answer to the question: in whom of four subjects you are eager to prescribe oral anticoagulants (either warfarin or the newer oral alternatives)?, and what is considered as a main determinant for taking decision? Please consider only one: age, gender, diabetes, hypertension (systemic), cardiac dimension, LA dimension.
Nice question, indeed! Congrats!
For me all of patients should be under OAC.
The most important factor in primary prevention is age. There is a nice paper by L Friberg in Circulation where the authors show the importance of age in the increased risk for stroke.
As Guidelines say we will improve the prognosis of our patients initiating OAC in most of the cases. So, I am not clear we should say "her only risk factors are..."
To the best of my knowledge, we should not calculate +1 or +2 points. CHA2DS2-VASc and HAS-BLED score were not proposed to add or subtract points.
Regarding echo findings, for my only LV systolic function is an established variable.
Best wishes,