CHA2DS2-VASc and HAS-BLED scores in atrial fibrillation

Purpose. CHA DS -VASc estimates the annual risk of ischaemic stroke and systemic thromboembolism in non-2 2 valvular atrial fibrillation and decides who needs oral anticoagulation. HAS-BLED estimates major bleeding risk on anticoagulation. Atrial fibrillation causes up to 30% of all ischaemic strokes and a 3.5-fold increase in cardiovascular and all-cause death.

CHA DS -VASc components (maximum 9).

Interpretation of CHA DS -VASc. Men ≥ 2 and women ≥ 3 → oral anticoagulation recommended. Men = 1, 2 2 women = 2 → anticoagulation should be considered. Men = 0, women = 1 → no antithrombotic therapy. Aspirin is not an acceptable alternative to anticoagulation. Practically, almost every patient aged 75 or over already scores 2 or more — age alone makes anticoagulation the default in geriatric practice.

HAS-BLED components (maximum 9). Hypertension (uncontrolled systolic BP > 160 mmHg) 1; Abnormal renal or liver function, 1 each; Stroke 1; Bleeding history or predisposition (including anaemia) 1; Labile INR (time in therapeutic range < 60%) 1; Elderly (age > 65) 1; Drugs (antiplatelets, NSAIDs) or alcohol excess, 1 each.

Interpretation of HAS-BLED. A score of ≥ 3 indicates high bleeding risk. A high HAS-BLED score is NOT a reason to withhold anticoagulation. Its purpose is to (i) identify and correct modifiable risk factors — control blood pressure, stop NSAIDs and unnecessary antiplatelets, limit alcohol, review renal function, avoid labile INR — and (ii) schedule earlier and more frequent review.

Geriatric considerations. Falls risk is a very poor reason to withhold anticoagulation — a patient would need to fall roughly 295 times a year for the bleeding risk to outweigh the stroke benefit. Assess frailty, cognition, adherence, swallowing, renal function and drug interactions instead. Use the integrated ABC pathway (Avoid stroke with anticoagulation, Better symptom control, Comorbidity and risk factor management), which improves outcomes in anticoagulated patients.

The 2024 ESC Guidelines for the Management of Atrial Fibrillation replaced CHA DS -VASc with the 2 2 CHA DS -VA score — sex category has been removed (maximum 7) because female sex is an age-dependent 2 2 risk modifier rather than an independent risk factor. Anticoagulation is recommended at a score ≥ 2 and should be considered at a score of 1. The ABC pathway has been reframed as the AF-CARE pathway (Comorbidity and risk factor management, Avoid stroke and thromboembolism, Reduce symptoms by rate and rhythm control, Evaluation and dynamic reassessment).