CHA₂DS₂-VA Score and Stroke Risk in Atrial Fibrillation

The largest amount of clinical data is available for the CHA₂DS₂-VASc score.

in which female sex is one of the parameters as a risk factor.
However, female sex is a risk factor at older age > 65 years (mainly due to hormonal changes).

and the question remains which sex should be used in a patient after transgender hormonal and surgical transition to the opposite sex.

The risk of thromboembolism (TE) and stroke is almost identical,

regardless of whether it is calculated using the CHA₂DS₂-VASc or the CHA₂DS₂-VA score.

CHA₂DS₂-VA score
Parameter	Criteria (at least 1 criterion must be met)	Points
Chronic heart failure (Chronic heart failure)	Symptoms or parameters of heart failure regardless of ejection fraction (HFrEF, HFmrEF, HFpEF).	1
Hypertension (Arterial hypertension)	Use of antihypertensive medication Blood pressure > 140/90 mmHg (at least 3 home measurements at intervals ≥ 1 day)	1
Age (≥ 75 years) (Age ≥ 75 years)	Patient age ≥ 75 years	2
Diabetes mellitus (Diabetes mellitus)	Type 1 or type 2 diabetes mellitus Fasting plasma glucose > 7 mmol/l HbA1c > 6,5 % Random plasma glucose > 11 mmol/l	1
Stroke (Stroke)	Ischemic stroke Transient ischemic attack Thromboembolism	2
Vascular disease (Vascular disease)	Coronary artery disease Angina pectoris Post-myocardial infarction Post-coronary revascularization CT coronary angiography (> 50 % stenosis) Positive exercise stress test Peripheral arterial disease Intermittent claudication Post-revascularization Aortic vascular disease Post-aortic intervention Atherosclerotic plaque in the aorta (≥ 4 mm)	1
Age (65–74 years) (Age 65–74 years)	Patient age 65–74 years	1

Ischemic stroke (IS)

Is the main statistical parameter used in the development of thromboembolic risk scoring systems in atrial fibrillation (AF).
Ischemic stroke causes symptoms in the patient that are diagnosed by the healthcare system and can be linked to AF.
Other thromboembolic events, for example:

hematuria, lower limb ischemia, or angina pectoris, are more difficult for the healthcare system to associate with AF.

Therefore, the term thromboembolic risk in AF generally refers to the risk of embolic ischemic stroke.

Atrial Fibrillation and Stroke Risk According to the CHA₂DS₂-VA Score (1 year)
CHA₂DS₂-VA Score	Stroke Risk (without NOAC)	Stroke Risk (with NOAC)
0	0,5 %	0,2 %
1	1,5 %	0,5 %
2	3 %	1,0 %
3	5 %	1,8 %
4	7 %	2,6 %
5	11 %	3,9 %
6	14 %	5,4 %
7	15 %	5,1 %
8	19 %	6,8 %

There is a consensus that anticoagulant therapy (OAC) in AF is indicated,

In anticoagulant therapy (OAC) and AF, the following exceptions apply:

OAC (preferably NOAC, or Warfarin) is always indicated regardless of the CHA₂DS₂-VA score if the patient has:

OAC (always Warfarin) is always indicated regardless of the CHA₂DS₂-VA score if the patient has:

Thromboembolism (Ischemic Stroke) and Atrial Fibrillation	Class
Oral anticoagulant therapy in patients with AF is indicated according to the CHA₂DS₂-VA score, regardless of whether AF is paroxysmal, persistent, permanent, symptomatic, or asymptomatic.	I
Oral anticoagulant therapy is recommended in patients with AF and CHA₂DS₂-VA score ≥ 2.	I
Oral anticoagulant therapy should be considered in patients with AF and CHA₂DS₂-VA score = 1.	IIa
Oral anticoagulant therapy (preferably NOAC) is indicated in all patients regardless of the CHA₂DS₂-VA score with hypertrophic cardiomyopathy or cardiac amyloidosis	I
Warfarin as anticoagulant therapy is indicated in all patients regardless of the CHA₂DS₂-VA score with a mechanical valve or mitral stenosis (moderate or severe)	I
Oral anticoagulant therapy may be considered in patients with subclinical AF (with detected AHRE).	IIb
It is recommended to reassess the CHA₂DS₂-VA score regularly (every 6–12 months), or when the patient’s condition changes (reaches 65 years of age, develops hypertension, diabetes mellitus, etc.).	I

AHRE (Atrial High Rate Episodes)

AHRE is an episode of atrial tachyarrhythmia lasting > 5 min and with a rate > 170/min.
AHRE detected by a CIED atrial lead may represent: