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Instructions

Intended for patients with atrial fibrillation (AF) who do not have a prior history of stroke or transient ischemic attack (TIA) and are under consideration for anticoagulation therapy.
The inclusion of sex as an independent risk factor for ischemic stroke in patients with AF has been controversial; this score does not include sex in its risk assessment.
Has a predictive value similar to the CHA₂DS₂-VASc Score

Age

Introduction

The CHA₂DS₂-VA score estimates the risk of stroke and systemic thromboembolism in patients with atrial fibrillation (AF). Its main use is guiding the decision to start oral anticoagulation. It was introduced in the 2024 European Society of Cardiology (ESC) AF guidelines as a replacement for the CHA₂DS₂-VASc score. It is identical to that score except that it drops the “Sc” (sex category) point for female sex.

Variables & Scoring

Addition of the selected points.

Variable	Points
Age	<65	0
65-74	1
≥75	2
Chronic heart failure	No	0
Yes	1
Hypertension	No	0
Yes	1
Prior stroke, TIA, or arterial thromboembolism	No	0
Yes	2
Vascular disease	No	0
Yes	1
Diabetes mellitus	No	0
Yes	1

Interpretation

CHA₂DS₂-VA Score	Ischemic Stroke Incidence Rate (per 100 Patient Years)	Recommendation
0	0.5	Anticoagulation is not recommended
1	1.5	Anticoagulation should be considered to reduce stroke risk along with clinical judgement to weigh the risks and benefits of anticoagulation.
2	2.9	Anticoagulation should be recommended to reduce stroke risk for scores of ≥2.
3	5.1
4	7.3
5	11.2
6	15.5
7	14.7
8	19.5

Under the 2024 ESC guidelines, a score of 2 or more means oral anticoagulation is recommended (Class I). A score of 1 means anticoagulation should be considered (Class IIa), weighing individual factors and patient preference. A score of 0 means anticoagulation is not recommended for stroke prevention. Higher scores mean higher annual stroke risk, and direct oral anticoagulants are generally preferred over warfarin for eligible patients.

Management considerations

Risk and benefits of anti-coagulation should be considered in patients, to include shared decision-making and informed consent, prior to initiating therapy.
Refer to the ESC guidelines for the management of AF for additional recommendations.
Clinical judgement and best practice guidelines supersedes adjunct standalone decision tools.
Periodically reassess stroke risk.
Other risk stratification tools to consider include:

Why sex was removed

Female sex is now viewed as a risk modifier rather than an independent risk factor. It mainly raises stroke risk in older women who already have other risk factors, and contributes little on its own. Dropping it brings several benefits. It simplifies treatment thresholds, which previously differed by sex (≥ 2 for men, ≥ 3 for women under CHA₂DS₂-VASc). It avoids the problem that a woman with no other risk factors scored 1 point despite low actual risk. And it applies cleanly to patients who are transgender, nonbinary, or receiving gender-affirming hormone therapy.

Limitations and context

The score does not apply to AF patients with mechanical heart valves or moderate-to-severe mitral stenosis. Anticoagulation is indicated regardless of score in those patients, typically with warfarin. The same is generally true for conditions such as hypertrophic cardiomyopathy and cardiac amyloidosis.

The score also leaves out other factors that influence stroke risk, such as chronic kidney disease, AF burden, and left atrial size. Bleeding risk should be assessed separately, ideally by identifying and addressing modifiable bleeding risk factors rather than using a bleeding score to withhold anticoagulation.

Guidelines also vary by region. The 2023 ACC/AHA/ACCP/HRS guideline in the United States still uses CHA₂DS₂-VASc, so the choice of score may depend on which guideline your institution follows.

All questions & possible results

QuestionsTitle not visible

Age

Select one option:

< 65
65 - 74
≥ 75

Congestive Heart Failure (CHF) history

Select one option:

Hypertension history

Select one option:

Stroke/TIA/thromboembolism history

Select one option:

Vascular disease history (prior MI, peripheral artery disease, or aortic plaque)

Select one option:

Diabetes history

Select one option:

Possible results

CHA2DS2-VA Score: Anticoagulation should be considered to reduce stroke risk according to clinical judgement.

Ischemic stroke incidence rate: 1.5 per 100 patient years.
Use clinical jugmentment and weight the risk and benefits of anti-coagulation, to include shared decision-making and informed consent, prior to initiating therapy.
Refer to the ESC guidelines for the management of AF for additional recommendations.
Clinical judgement and best practice guidelines supersedes adjunct standalone decision tools.
Periodically reassess stroke risk.
Other risk stratification tools to consider include: