I. How to Use

When to Use

Use in patients with atrial fibrillation (AF) to estimate the one-year risk of a thromboembolic event and to guide decisions regarding OAC initiation.

Pearls / Pitfalls

Female sex is an age- and comorbidity-dependent risk modifier of ischaemic outcomes in AF rather than an independent risk factor; thus, the inclusion of sex has been controversial. The CHA₂DS₂-VA score is an updated tool to estimate the sex-independent risk of adverse outcomes in patients with AF. Note, however, that its primary outcome is a composite measure of all-cause mortality, ischaemic stroke, and arterial thromboembolism, and that patients aged ≥75 years or with a history of stroke were excluded from the derivation cohort (with the latter being of particular relevance given that a history of previous stroke represents an important determinant of ischaemic risk). The overall discrimination of the score is modest and thus should always be considered alongside clinical judgment. The presence of other pro-thrombotic risk factors such as cancer, chronic kidney disease, ethnicity (black, Hispanic, Asian), and biomarkers (troponin and BNP), and in specific groups such as those with atrial enlargement, hyperlipidaemia, smoking, and obesity, should be considered alongside individual CHA₂DS₂-VA score points. Indeed, interpretation of this score in such patients should be made with caution and with consideration of individual clinical contexts. For patients with hypertrophic cardiomyopathy or cardiac amyloidosis, OAC should be considered irrespective of the CHA₂DS₂-VA score (Class I, Level B; ESC 2024 guidelines).

Why Use

Assesses a patient’s sex-independent risk for adverse outcomes (i.e., all-cause mortality, stroke, arterial thromboembolism) and identifies patients with atrial fibrillation (in the absence of mechanical heart valves and/or moderate-to-severe mitral stenosis) who may benefit from anticoagulation therapy to prevent thromboembolic events. Pending additional validation studies, its predictive performance appears to be similar to the CHA₂DS₂-VAsc score without relying on sex. Endorsed as the primary risk prediction tool by the European Society of Cardiology (ESC) guidelines 2024 for the management of patients with AF.

II. Next Steps

Advice

Use the CHA₂DS₂-VA score - without any sex/gender criterion - to guide decisions regarding OAC therapy. Until more trial data are available, prescribe OAC for scores ≥2 and consider it for score 1 through shared, patient-centred discussion, considering individual bleeding risk (e.g., consider using the HAS-BLED score) and management thereof if modifiable. Clinicians should also assess additional thromboembolic risk factors, with OAC therapy being recommended irrespective of score points in those with hypertrophic cardiomyopathy or cardiac amyloidosis. Reassess risk at periodic intervals.

Management

According to the 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery:

Recommendation Class Level
Oral anticoagulation is recommended in patients with clinical AF at elevated thromboembolic risk to prevent ischaemic stroke and thromboembolism. I A
A CHA₂DS₂-VA score of 2 or more is recommended as an indicator of elevated thromboembolic risk for decisions on initiating oral anticoagulation. I C
Oral anticoagulation is recommended in all patients with AF and hypertrophic cardiomyopathy or cardiac amyloidosis, regardless of CHA₂DS₂-VA score, to prevent ischaemic stroke and thromboembolism. I B
Individualized reassessment of thromboembolic risk is recommended at periodic intervals in patients with AF to ensure anticoagulation is started in appropriate patients. I B
A CHA₂DS₂-VA score of 1 should be considered an indicator of elevated thromboembolic risk for decisions on initiating oral anticoagulation. IIa C
Direct oral anticoagulant therapy may be considered in patients with asymptomatic device-detected subclinical AF and elevated thromboembolic risk to prevent ischaemic stroke and thromboembolism, excluding patients at high risk of bleeding. IIb B
Antiplatelet therapy is not recommended as an alternative to anticoagulation in patients with AF to prevent ischaemic stroke and thromboembolism. III A
Using the temporal pattern of clinical AF (paroxysmal, persistent, or permanent) is not recommended to determine the need for oral anticoagulation. III B

Critical Actions

Weigh the risks (specifically bleeding risk, e.g. estimated by the HAS-BLED score) and benefits of initiating OAC therapy carefully and discuss them thoroughly with the patient for shared decision making. Ensure proper clinical management of modifiable bleeding risk factors. Importantly, the overall discrimination of the score is modest and thus should always be considered alongside clinical judgement. Other pro-thrombotic risk factors—including cancer, chronic kidney disease, ethnicity (Black, Hispanic, Asian), elevated biomarkers (troponin and BNP), atrial enlargement, hyperlipidaemia, smoking, and obesity—should also be considered alongside individual CHA₂DS₂-VA score points. Indeed, interpretation of this score in such patients should be made with caution and with consideration of individual clinical contexts.

III. Evidence

Evidence Appraisal

The CHA₂DS₂-VASc score was introduced as an expansion of CHADS₂ to better stratify 1-year thromboembolic risk in atrial fibrillation (AF) in the absence of mechanical heart valves and/or moderate-to-severe mitral stenosis. Despite methodological limitations in its derivation—such as exclusion of many patients due to missing outcome data and lack of adjustment for competing mortality—the score has been extensively validated across diverse cohorts. Its overall discrimination is modest (c-statistic ~0.6–0.7), only slightly better than CHADS₂, but its strength lies in reliably identifying truly low-risk patients who do not require anticoagulation. This negative predictive value made it clinically valuable and ensured widespread adoption in international AF guidelines. Although the score has been explored in other settings, its primary role remains guiding anticoagulation in AF in the absence of mechanical heart valves and/or moderate-to-severe mitral stenosis. As evidence evolved, the role of sex as a risk factor became increasingly controversial. Multiple studies demonstrated that removing sex from CHA₂DS₂-VASc produces comparable or even slightly improved risk discrimination. This led the 2024 ESC guidelines to endorse the CHA₂DS₂-VA score, which drops sex entirely. Beyond simplifying anticoagulation thresholds—0 to withhold anticoagulation, 1 to consider it, and ≥2 to recommend it—the change increases inclusivity for non-binary and transgender individuals. Recent analyses support this approach: Teppo et al. (2024) found CHA₂DS₂-VA performs similarly to CHA₂DS₂-VASc, Champsi et al. reported slightly superior discrimination, and the GLORIA-AF registry showed comparable performance, although it noted potential interactions between female sex and age.

The CHA₂DS₂-VA score represents a practical, sex-independent update that aligns with contemporary evidence and clinical practice, but its limitations are important. Its derivation relied on a composite endpoint (all-cause mortality, ischaemic stroke, arterial thromboembolism), meaning it does not isolate stroke-specific risk. Patients aged <40 or ≥75 years were excluded in the study by Champsi et al., limiting applicability in young and old patients, respectively. Moreover, patients with a history of previous stroke were excluded, with stroke representing a key determinant of ischaemic risk. Finally, like its predecessors, its predictive ability remains modest and should be interpreted alongside clinical judgement rather than used in isolation.

Overall, the CHA₂DS₂-VA score is now the guideline-endorsed tool (2024 ESC Guidelines for the Management of Atrial Fibrillation Developed in Collaboration with the European Association for Cardio-Thoracic Surgery) for assessing thromboembolic risk in AF and performs similarly to CHA₂DS₂-VASc. However, its modest discrimination, reliance on a composite primary endpoint, and exclusion of patients ≥75 years in the initial derivation cohort highlight important limitations. As AF epidemiology and management continue to evolve, further refinement of risk-prediction tools will likely be necessary.

Formula

Variable Points
Chronic heart failure Symptoms and signs of heart failure (irrespective of LVEF, thus including HFpEF, HFmrEF, and HFrEF), or the presence of asymptomatic LVEF ≤40% 1
Hypertension Resting blood pressure >140/90 mmHg on at least two occasions, or current antihypertensive treatment. The optimal BP target associated with lowest risk of major cardiovascular events is 120–129/70–79 mmHg (or keep as low as reasonably achievable) 1
Age 75 years or above Age is an independent determinant of ischaemic stroke risk. Age-related risk is a continuum, but for reasons of practicality, two points are given for age ≥75 years. 2
Diabetes mellitus Diabetes mellitus (type 1 or type 2), as defined by currently accepted criteria or treatment with glucose lowering therapy. 1
Stroke (prior), TIA, or arterial thromboembolism Previous thromboembolism is associated with highly elevated risk of recurrence and therefore weighted 2 points. 2
Vascular disease Coronary artery disease, including prior myocardial infarction, angina, history of coronary revascularization (surgical or percutaneous), and significant CAD on angiography or cardiac imaging.
OR
Peripheral vascular disease, including: intermittent claudication, previous revascularization for PVD, percutaneous or surgical intervention on the abdominal aorta, and complex aortic plaque on imaging (defined as features of mobility, ulceration, pedunculation, or thickness ≥4 mm)		 1
Age 65–74 years 1 point is given for age between 65 and 74 years. 1

Literature

Original/Primary

https://pubmed.ncbi.nlm.nih.gov/39217497/
Champsi A, Mobley AR, Subramanian A, et al. Gender and contemporary risk of adverse events in atrial fibrillation. European Heart Journal. 2024;45(36):3707-3717.

Validation

https://pubmed.ncbi.nlm.nih.gov/39171253/
Teppo K, Lip GYH, Airaksinen KEJ, et al. Comparing CHA2DS2-VA and CHA2DS2-VASc scores for stroke risk stratification in patients with atrial fibrillation: a temporal trends analysis from the retrospective Finnish AntiCoagulation in Atrial Fibrillation (Finacaf) cohort. The Lancet Regional Health - Europe. 2024;43:100967.

Ho Man Lam S, Romiti GF, Corica B et al., Stroke risk stratifications according to CHA2DS2-VASc vs. CHA2DS2-VA in patients with atrial fibrillation: insights from the GLORIA-AF registry. Eur Heart J Cardiovasc Pharmacother. 2025

Guidelines

https://pubmed.ncbi.nlm.nih.gov/38033089/
Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193. Epub 2023 Nov 30. Erratum in: Circulation. 2024;149(1):e167. doi:10.1161/CIR.0000000000001207.

https://pubmed.ncbi.nlm.nih.gov/39210723/
Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, et al. 2024 ESC Guidelines for the Management of Atrial Fibrillation Developed in Collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024;45(18):ehae176. doi:10.1093/eurheartj/ehae176.