Published in:
01-01-2018 | Editorial
CHAD is Dead: Pragmatic Utility of the CHA2DS2-VASc Score in Non-Valvular Atrial Fibrillation?
Published in: Journal of General Internal Medicine | Issue 1/2018
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The CHADS2 score and its second iteration, CHA2DS2-VASc, are ubiquitous in clinical decisions pertaining to assessment of a patient’s thromboembolic risk from non-valvular atrial fibrillation (AF). Clinicians rely on these scores when deciding whether to prescribe long-term oral anticoagulation (OAC) for AF patients, weighing the bleeding risks of OAC against the actuarial risk of an embolic stroke. However, societal guidelines have incrementally expanded indications for anticoagulant use through the addition of novel risk factors and lowering the threshold for initiation of OAC.1 In fact, O’Brien et al. recently demonstrated that 91% of patients with non-valvular AF now have a guideline-based indication for anticoagulation.2 Despite the overwhelming eligibility patients for OAC, a recent retrospective study of patients with non-valvular AF who suffered an acute ischemic stroke demonstrated that only 16% of eligible stroke patients were receiving therapeutic anticoagulation.3 Given this background, we argue that:
1.
The clinician's focus should be on when to initiate OAC, or alternatively, on identifying those rare circumstances in which not to initiate OAC.
2.
The CHADS2 and CHA2DS2-VASc scores may not be relevant for clinical decision-making.
3.
Risk scores foster clinical inertia, creating a barrier to guideline-directed care.