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CHA₂DS₂-VASc

for Atrial Fibrillation Stroke Risk

and

HAS-BLED Score

Estimating the risk of major bleeding for patients on anticoagulation to assess risk-benefit in atrial fibrillation care
by Dr. Ufuk Ali TÜRK
Ver.

CHA₂DS₂-VASc and HAS-BLED Score

for Atrial Fibrillation Stroke Risk
Estimating the risk of major bleeding for patients on anticoagulation to assess risk-benefit in atrial fibrillation care
by Dr. Ufuk Ali TÜRK
Ver.
CHA₂DS₂-VASc Score: 0
Stroke risk was 0.2% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 0.3% risk of stroke/TIA/systemic embolism.
One recommendation suggests a 0 score is “low” risk and may not require anticoagulation
Stroke risk was 0.6% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 0.9% risk of stroke/TIA/systemic embolism.
One recommendation suggests a 1 score is “low-moderate” risk and should consider antiplatelet or anticoagulation.
Stroke risk was 2.2% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 2.9% risk of stroke/TIA/systemic embolism.
Stroke risk was 3.2% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 4.6% risk of stroke/TIA/systemic embolism.
Stroke risk was 4.8% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 6.7% risk of stroke/TIA/systemic embolism.
Stroke risk was 7.2% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 10.0% risk of stroke/TIA/systemic embolism.
Stroke risk was 9.7% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 13.6% risk of stroke/TIA/systemic embolism.
Stroke risk was 11.2% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 15.7% risk of stroke/TIA/systemic embolism.
Stroke risk was 10.8% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 15.2% risk of stroke/TIA/systemic embolism.
We realize that 8 points showed a lower risk than 7 points, these were the findings in the study, obviously one should assume all scores ≥7 have a risk >10%.
Stroke risk was 12.2% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 17.4% risk of stroke/TIA/systemic embolism.
One recommendation suggests a 2 or greater score is “moderate-high” risk and should otherwise be an anticoagulation candidate.
HAS-BLED Score: 0
Risk was 0.9% in one validation study and 1.13 bleeds per 100 patient-years in another validation study.
Anticoagulation should be considered: Patient has a relatively low risk for major bleeding (~1/100 patient-years).
Risk was 3.4% in one validation study and 1.02 bleeds per 100 patient-years in another validation study.
Anticoagulation should be considered: Patient has a relatively low risk for major bleeding (~1/100 patient-years).
Risk was 4.1% in one validation study and 1.88 bleeds per 100 patient-years in another validation study.
Anticoagulation can be considered, however patient does have moderate risk for major bleeding (~2/100 patient-years).
Risk was 5.8% in one validation study and 3.72 bleeds per 100 patient-years in another validation study.
Alternatives to anticoagulation should be considered: Patient is at high risk for major bleeding.
Risk was 8.9% in one validation study and 8.70 bleeds per 100 patient-years in another validation study.
Alternatives to anticoagulation should be considered: Patient is at high risk for major bleeding.
Risk was 9.1% in one validation study and 12.50 bleeds per 100 patient-years in another validation study.
Alternatives to anticoagulation should be considered: Patient is at high risk for major bleeding.
Scores greater than 5 were too rare to determine risk, but are likely over 10%.
Alternatives to anticoagulation should be considered: Patient is at very high risk for major bleeding.
Scores greater than 5 were too rare to determine risk, but are likely over 10%.
Alternatives to anticoagulation should be considered: Patient is at very high risk for major bleeding.
Scores greater than 5 were too rare to determine risk, but are likely over 10%.
Alternatives to anticoagulation should be considered: Patient is at very high risk for major bleeding.
Scores greater than 5 were too rare to determine risk, but are likely over 10%.
Alternatives to anticoagulation should be considered: Patient is at very high risk for major bleeding.

Creatinine Clearance

(Cockcroft-Gault Formula)
Age (years)
Weight (kg)
Creatinine (mg/dL)
Sex
Creatinine Clearance (mL/min)

NOACs' Recommended Dosages

Verapamil usage
DESK usage
(Dronedaron, Eritromisin, Siklosporin or Ketokonazol)

+ Show NOACs' Recommended Dosages
− Hide NOACs' Recommended Dosages
Pradaxa® (Dabigatran)
Xarelto® (Rivaroksaban)
Eliquis® (Apiksaban)
Lixiana® (Edoksaban)

Coagulation Pathways and Effects of NOACs

NOACs' Effect on Coagulation Tests

What To Do Before Surgery

What To Do When Bleeding

Coagulation Tests While Using NOACs


CHA₂DS₂-VASc

Age
Sex
CHF history
Hypertension history
Stroke, TIA or thromboembolism history
Vascular disease history
Diabetes history
− Hide CHA₂DS₂-VASc Info
CHA₂DS₂-VASc ScoreRisk of ischemic strokeRisk of stroke/TIA/systemic embolism
00.2%0.3%
10.6%0.9%
22.2%2.9%
33.2%4.6%
44.8%6.7%
57.2%10.0%
69.7%13.6%
711.2%15.7%
810.8%15.2%
912.2%17.4%
Article: Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.
Lip GY1, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ.
Chest. 2010 Feb;137(2):263-72. doi: 10.1378/chest.09-1584. Epub 2009 Sep 17.

HAS-BLED

Hypertension
Uncontrolled, >160 mmHg systolic
Renal disease
Dialysis, transplant, Cr >2.26 mg/dL or >200 µmol/L
Liver disease
Cirrhosis or bilirubin >2x normal with AST/ALT/AP >3x normal
Stroke history
Prior major bleeding or predisposition to bleeding
Labile INR
Unstable/high INRs, time in therapeutic range <60%
Age >65
Medication usage predisposing to bleeding
Aspirin, clopidogrel, NSAIDs
Alcohol use
≥8 drinks/week
− Hide HAS-BLED Info
HAS-BLED ScoreRisk groupRisk of major bleedingBleeds per 100 patient-yearsRecommendation
0Relatively low0.9%1.13Anticoagulation should be considered
13.4%1.02
2Moderate4.1%1.88Anticoagulation can be considered
3High5.8%3.72Alternatives to anticoagulation should be considered
48.9%8.70
59.1%12.50
>5*Very high----
*Scores greater than 5 were too rare to determine risk, but are likely over 10%.
Article: A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey.
Pisters R1, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY.
Chest. 2010 Nov;138(5):1093-100. doi: 10.1378/chest.10-0134. Epub 2010 Mar 18.

− Hide STENT Info
Haemorrhagic risk Stroke risk Clinical setting Recommendations according to EHRA / ESC / EAPCI 2014 consensus document
Low or moderate
(HAS-BLED 0-2)
Moderate
(CHA2DS2-VASC = 1 in males)
Stable CAD
At least 4 weeks (no longer than 6 months): triple therapy of OAC + aspirin 75-100 mg/day + clopidogrel 75 mg/day
Up to 12th month: OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75-100 mg/day)
Lifelong: OAC
High
(CHA2DS2-VASC ≥2)
Stable CAD
At least 4 weeks (no longer than 6 months): triple therapy of OAC + aspirin 75-100 mg/day + clopidogrel 75 mg/day
Up to 12th month: OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75-100 mg/day)
Lifelong: OAC
Moderate
(CHA2DS2-VASC = 1 in males)
ACS
6 months: triple therapy of OAC + aspirin 75-100 mg/day + clopidogrel 75 mg/day
Up to 12th month: OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75-100 mg/day)
Lifelong: OAC
High
(CHA2DS2-VASC ≥2)
ACS
6 months: triple therapy of OAC + aspirin 75-100 mg/day + clopidogrel 75 mg/day
Up to 12th month: OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75-100 mg/day)
Lifelong: OAC
High
(HAS-BLED ≥3)
Moderate
(CHA2DS2-VASC = 1 in males)
Stable CAD
Up to 12th month: OAC and clopidogrel 75 mg/day
Lifelong: OAC
High
(CHA2DS2-VASC ≥2)
Stable CAD
4 weeks: triple therapy of OAC + aspirin 75-100 mg/day + clopidogrel 75 mg/day
Up to 12th month: OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75-100 mg/day)
Lifelong: OAC
Moderate
(CHA2DS2-VASC = 1 in males)
ACS
4 weeks: triple therapy of OAC + aspirin 75-100 mg/day + clopidogrel 75 mg/dayd
Up to 12th month: OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75-100 mg/day)
Lifelong: OAC
High
(CHA2DS2-VASC ≥2)
ACS
4 weeks: triple therapy of OAC + aspirin 75-100 mg/day + clopidogrel 75 mg/dayd
Up to 12th month: OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75-100 mg/day)
Lifelong: OAC

Please be aware that the CHA2DS2Vasc risk score is only validated in non-valvular atrial fibrillation! For educational purposes only. By Jonas de Jong, MD, PhD, cardiologist. Suggestions for improvement are welcome at: dejong@stoneripple.com . .
References: