Stroke risk in atrial fibrillation (2024 ESC, sex-free)

What it is and when to use it

CHA₂DS₂-VA is the stroke-risk score introduced by the 2024 ESC guidelines for the management of atrial fibrillation. It is the established CHA₂DS₂-VASc score with the sex category removed: it adds points for congestive heart failure, hypertension, age (one point at 65–74, two from 75), diabetes, prior stroke or TIA, and vascular disease, for a maximum of 8. Removing sex simplifies the decision and applies the same threshold to men and women.

How to interpret it

A score of 0 indicates low risk and oral anticoagulation is not recommended. A score of 1 lies in an intermediate band where anticoagulation should be considered (ESC Class IIa). From 2 points upward, oral anticoagulation is recommended (Class I). Because sex is no longer scored, women and men with the same risk factors receive the same recommendation.

Limitations and when not to use it

CHA₂DS₂-VA does not apply to patients with a mechanical heart valve or moderate-to-severe mitral stenosis, in whom anticoagulation with a vitamin K antagonist is indicated regardless of the score. It estimates thrombotic risk only and does not assess bleeding risk, which is evaluated separately, for example with the HAS-BLED score. The score informs but does not replace individualised clinical judgement, and it does not provide a per-point annual stroke percentage.

Frequently asked questions

What is the difference between CHA₂DS₂-VA and CHA₂DS₂-VASc?

CHA₂DS₂-VA removes the sex (Sc) category. The 2024 ESC guidelines adopted it to simplify the decision, so the maximum score is 8 instead of 9 and the same thresholds apply to men and women.

Which CHA₂DS₂-VA score requires anticoagulation?

Oral anticoagulation is recommended from a score of 2 (ESC Class I) and should be considered at a score of 1 (Class IIa). A score of 0 does not warrant anticoagulation.

Does CHA₂DS₂-VA measure bleeding risk?

No. It estimates stroke (thrombotic) risk only. Bleeding risk is assessed separately, for example with the HAS-BLED score.