CHA₂DS₂-VA
Stroke risk in atrial fibrillation (ESC 2024, sex removed)
- ESC 2024 AF guideline
Sources last checked: 2026-10-13
CHA₂DS₂-VA
Stroke risk in atrial fibrillation (ESC 2024, sex removed)
On the score alone, ESC 2024 does not generally indicate oral anticoagulation; the score rises as risk factors accrue.
ESC 2024 dropped the sex category; the older CHA₂DS₂-VASc gives 1 point for female sex. Check which version your local protocol uses.
Interpretation
| 0 — low | On the score alone, ESC 2024 does not generally indicate oral anticoagulation; the score rises as risk factors accrue. |
|---|---|
| 1 — elevated | ESC 2024: oral anticoagulation should be considered in this group (class IIa), with shared decision-making. |
| ≥ 2 — high | ESC 2024 recommends oral anticoagulation in this group (class I). |
What is the CHA₂DS₂-VA?
CHA₂DS₂-VA estimates the risk of ischaemic stroke and systemic thromboembolism in atrial fibrillation and is the score the 2024 ESC atrial fibrillation guideline uses to guide oral anticoagulation. It is the CHA₂DS₂-VASc score (Lip et al., Euro Heart Survey, 2010) with the female-sex point removed, so men and women with the same risk factors get the same score. The maximum is 8 points.
When to use it
- Adults with clinical (ECG-documented) atrial fibrillation or atrial flutter — the population in which ESC 2024 links the score to its oral anticoagulation recommendation.
- At every follow-up visit — risk factors such as hypertension, diabetes or age 65/75 accrue over time and change the score.
- When documenting the indication for a DOAC or vitamin K antagonist in the discharge letter or referral.
When not to use it
- Atrial fibrillation with hypertrophic cardiomyopathy or cardiac amyloidosis — ESC 2024 recommends anticoagulation regardless of the score.
- Moderate-to-severe mitral stenosis or a mechanical heart valve — these patients need a vitamin K antagonist irrespective of the score.
- Device-detected subclinical AF only: the evidence base and recommendations differ from clinical AF.
How it is calculated
| Criterion | Points |
|---|---|
| Chronic heart failure (any LVEF) or asymptomatic LVEF ≤ 40 % | +1 |
| Hypertension | +1 |
| Age ≥ 75 | +2 |
| Diabetes mellitus | +1 |
| Prior stroke / TIA / arterial thromboembolism | +2 |
| Vascular disease (CAD incl. prior MI, PAD, complex aortic plaque) | +1 |
| Age 65–74 | +1 |
Clinical pearls and limitations
- ESC 2024 dropped the sex category; the older CHA₂DS₂-VASc gives 1 point for female sex. Check which version your local protocol uses.
- ESC 2024: a score ≥ 2 → oral anticoagulation recommended (class I); a score of 1 → should be considered (class IIa), with shared decision-making.
- Age 65–74 scores 1 and age ≥ 75 scores 2 — never both. This calculator counts age only once if both boxes are ticked.
- Heart failure counts irrespective of ejection fraction (HFpEF, HFmrEF, HFrEF) or as asymptomatic LVEF ≤ 40 %; vascular disease includes significant CAD on imaging and complex aortic plaque.
- The score does not include bleeding risk. Modifiable bleeding risk factors are assessed separately; under ESC 2024 a bleeding score is never by itself a reason to withhold anticoagulation.
- Other markers that raise stroke risk (cancer, CKD, left atrial enlargement, elevated biomarkers) are not scored but can tip a borderline decision.
Frequently asked questions
At what CHA₂DS₂-VA score should I anticoagulate?
Under the 2024 ESC guideline, oral anticoagulation is recommended from a score of 2 and should be considered at a score of 1. At 0, anticoagulation is generally not indicated on the score alone, but the score changes as the patient ages or develops new risk factors.
What is the difference between CHA₂DS₂-VA and CHA₂DS₂-VASc?
CHA₂DS₂-VASc adds 1 point for female sex. ESC 2024 removed that point because female sex acts as a risk modifier rather than an independent risk factor, and a sex-neutral score simplifies decisions. A woman with no other risk factor scores 0 on CHA₂DS₂-VA instead of 1 on CHA₂DS₂-VASc.
Do US guidelines also use CHA₂DS₂-VA?
The 2023 ACC/AHA/ACCP/HRS guideline still refers to CHA₂DS₂-VASc. Check which version your local pathway uses; the thresholds are not interchangeable.
Does paroxysmal AF need anticoagulation as well?
Yes. ESC 2024 recommends against using the temporal pattern of AF (paroxysmal, persistent or permanent) to decide on anticoagulation — the decision follows thromboembolic risk, not AF type.
Evidence and guidelines
- Primary source: Van Gelder IC et al. 2024 ESC Guidelines for the management of atrial fibrillation. Eur Heart J 2024;45(36):3314-3414 (Table 10, Recommendation Table 6).
- Lip GYH et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation (CHA₂DS₂-VASc derivation, Euro Heart Survey). Chest 2010;137(2):263-272.
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<p><a href="https://medelix.ai/en/calculators/cha2ds2-va-score">CHA₂DS₂-VA calculator by Medelix</a></p>For healthcare professionals and medical students. These tools support, and do not replace, clinical judgement. Always check results against the original source and your local protocols.