New concepts and approaches to stroke prevention in the new European Society of Cardiology guidelines for the management of atrial fibrillation

Figures & data

Figure 1. Clinical flowchart for thromboprophylaxis in atrial fibrillation.

^†Other stroke risk factors can be classified as ‘major’ risk factors and ‘clinically relevant non-major’ risk factors, that can also be expressed as the CHA₂DS₂-VASc score (see Table 1).

CHADS₂: Congestive heart failure, hypertension, age 75 years or older, diabetes, stroke (doubled); CHA₂DS₂-VASc: Congestive heart failure/LV dysfunction, hypertension, aged ≥75 years (doubled), diabetes mellitus, prior stroke/TIA/TE (doubled)–vascular disease, aged 65–74 years, sex category; EF: Ejection fraction; OAC: Oral anticoagulation therapy; TE: Thromboembolism; TIA: Transient ischemic attack.

Table 1. Assessment of stroke (CHA₂DS₂-VASc) and bleeding risk (HAS-BLED).

CHA2DS2-VASc	Score	HAS-BLED	Score
Congestive heart failure	1	Hypertension (SBP >160 mmHg)	1
Hypertension	1	Abnormal renal and liver function (1 point each)	1 or 2
Age ≥75 years	2	Stroke	1
Diabetes mellitus	1	Bleeding	1
Stroke/TIA/TE	2	Labile INRs	1
Vascular disease (prior MI, PAD or aortic plaque)	1	Elderly (e.g., age >65 years)	1
Age 65–74 years	1	Drugs or alcohol (1 point each)	1 or 2
Female gender	1
Maximum score	9	Maximum score	9

CHA₂DS₂-VASc score of 0: recommend no antithrombotic therapy.

Score of 1: recommend antithrombotic therapy with oral anticoagulation or antiplatelet therapy, but preferably oral anticoagulation.

Score ≥2: recommend oral anticoagulation. HAS-BLED score of ≥3 suggests increased bleeding risk and warrants some caution and/or regular review.

CHA₂DS₂-VASc: Congestive heart failure/LV dysfunction, hypertension, aged ≥75 years (doubled), diabetes mellitus, prior stroke/TIA/TE (doubled)–vascular disease, aged 65–74 years, sex category; HAS-BLED: Hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly (e.g., >65 years of age), drugs/alcohol concomitantly; INR: International normalized ratio; MI: Myocardial infarction; PAD: Peripheral artery disease; SBP: Systolic blood pressure; TE: Thromboembolism; TIA: Transient ischemic attack.