CHA₂DS₂-VASc
Stroke risk in atrial fibrillation (classic score incl. female sex)
- Euro Heart Survey (derivation)
- ESC 2020 AF guideline
Sources last checked: 2026-10-13
CHA₂DS₂-VASc
Stroke risk in atrial fibrillation (classic score incl. female sex)
Superseded in the ESC 2024 AF guideline by CHA₂DS₂-VA, which drops the sex point. Use this classic version when your local pathway, a trial protocol or a non-ESC guideline still refers to CHA₂DS₂-VASc.
Interpretation
| 0 — low | Men with 0 points: ESC 2020 does not recommend antithrombotic therapy for stroke prevention. |
|---|---|
| 1 | Men: ESC 2020 states that OAC should be considered. Women with 1 point (sex alone): low risk, for which ESC 2020 sees no OAC indication. |
| 2 | Men: ESC 2020 recommends OAC. Women: ESC 2020 states that OAC should be considered. |
| ≥ 3 | OAC recommended in both sexes (ESC 2020: ≥ 2 in men, ≥ 3 in women). |
What is the CHA₂DS₂-VASc?
CHA₂DS₂-VASc estimates the risk of stroke and systemic embolism in non-valvular atrial fibrillation. It was derived by Lip and colleagues in 2010 from the Euro Heart Survey on AF, extending CHADS₂ with vascular disease, age 65–74 and female sex to better identify truly low-risk patients. The 2024 ESC AF guideline replaced it with CHA₂DS₂-VA, which is the same score without the sex point.
When to use it
- Looking up the ESC 2020 anticoagulation category in atrial fibrillation or flutter when a local pathway still uses CHA₂DS₂-VASc (e.g. ESC 2020-based protocols, many national and non-European guidelines).
- Reading trials, registries and older literature, which almost all report CHA₂DS₂-VASc.
- Comparing with CHA₂DS₂-VA to understand how the ESC 2024 change affects a woman's risk category.
When not to use it
- AF with moderate-to-severe mitral stenosis or a mechanical heart valve — anticoagulation is indicated regardless of the score.
- Patients already on OAC for another indication, where the score does not change management.
- As a bleeding-risk tool — use HAS-BLED for modifiable bleeding risk factors.
How it is calculated
| Criterion | Points |
|---|---|
| Congestive heart failure / LV dysfunction | +1 |
| Hypertension | +1 |
| Age | |
| < 65 years | 0 |
| 65–74 years | 1 |
| ≥ 75 years | 2 |
| Diabetes mellitus | +1 |
| Prior stroke / TIA / thromboembolism | +2 |
| Vascular disease (prior MI, PAD, aortic plaque) | +1 |
| Female sex | +1 |
Clinical pearls and limitations
- Superseded in the ESC 2024 AF guideline by CHA₂DS₂-VA, which drops the sex point. Use this classic version when your local pathway, a trial protocol or a non-ESC guideline still refers to CHA₂DS₂-VASc.
- Female sex is a risk modifier, not a risk factor on its own: a woman with no other factor scores 1 but is low risk.
- Thresholds are therefore sex-specific: OAC is recommended from 2 points in men and from 3 in women (ESC 2020).
- CHA₂DS₂-VA (ESC 2024) simply removes the sex point and uses one threshold for everyone — same patient, score one point lower in women.
- Risk is dynamic: re-score when patients age into a new band or develop hypertension, diabetes or heart failure.
Frequently asked questions
What is the difference between CHA₂DS₂-VASc and CHA₂DS₂-VA?
CHA₂DS₂-VA is identical except that the 1 point for female sex is removed. The ESC 2024 AF guideline adopted it so that one set of thresholds applies to both sexes.
At what CHA₂DS₂-VASc score is anticoagulation recommended?
Under ESC 2020, OAC is recommended at ≥ 2 in men and ≥ 3 in women, and should be considered at 1 in men and 2 in women.
Does a woman with a CHA₂DS₂-VASc of 1 need anticoagulation?
Under ESC 2020, no: if the single point comes from female sex alone, she is considered low risk and anticoagulation is not indicated.
What is the maximum CHA₂DS₂-VASc score?
9 points: age ≥ 75 and prior stroke/TIA count 2 each, the other five items 1 each.
Evidence and guidelines
- Primary source: Lip GYH, Nieuwlaat R, Pisters R, Lane DA, Crijns HJGM. 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. Chest 2010;137(2):263-272.
- Hindricks G et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation. Eur Heart J 2021;42:373-498.
- Van Gelder IC et al. 2024 ESC Guidelines for the management of atrial fibrillation (introduces CHA₂DS₂-VA). Eur Heart J 2024;45:3314-3414.
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