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Anticoagulation CHA2DS2-VASc Clinical Guidelines to Prevent A-Fib Stroke
by Steve S. Ryan, PhD
Background: “Guideline for the Management of Patients With Atrial Fibrillation” is official policy of the American College of Cardiology (ACC) and the American Heart Association (AHA). For clinical practices, they serve as a foundation for the delivery of quality cardiovascular care.
When you develop Atrial Fibrillation, you are at increased risk of clots and stroke. To help A-Fib doctors determine your risk for stroke or heart attack, they use the CHA2DS2-VASc assessment tool.
Not all doctors agree with its recommendations, some find serious fault with it. One of them is Dr. Mintu Turakhia, Professor of Cardiovascular Medicine at Stanford University.
“CHA2DS2-VASc is a stain on our field.” This statement by Dr. Mintu Turakhia at Stanford Un., CA, was made at the 2022 AF Symposium. A bold statement. This quote reflects the mixed feelings doctors have about these recommendations from Guidelines for the Management of Patients with Atrial Fibrillation.
But for better or worse, our doctors have to live with them. These Guidelines have become, in effect, the law of the land.
As patients we need to understand how these Guidelines work and what they mean for us when we have A-Fib.
CHA2DS2-VASc Risk Assessment
Here’s the CHA2DS2-VASc Risk Assessment tool. Try it—add up your own risk score.
| Risk Factor | Risk Score |
| Age 65-74 “A” Age over 75 “A2” | +1 +2 |
| Female sex “Sc” | +1 |
| CHF (Congestive Heart Failure) “C” | +1` |
| Hypertension (Uncontrolled High Blood Pressure) “H” (Over 140/90) | +1 |
| Stroke/TIA “S2” | +2 |
| Vascular Disease (Heart Attack, etc.) “V” | +2 |
| Diabetes “D” | +1 |
| Total score: |
How’d you do? According to the Guidelines, any risk score higher than zero for men and 1 for women dictate you should be on an anticoagulant.
Did you notice…that just being a 65-year-old female (2 pts.) automatically rates you at risk of stroke? Not taken into account were the patient’s fitness, level of activity, or even a family history of stroke. Is this an accurate assessment of stroke risk or is something lacking?
Beware: Guidelines “Recommend” Almost Everyone with A-Fib be on Anticoagulation
O
nly people with a risk score of 0 (males) and 1 (females) are considered low risk patients. What this means in practice is that almost everyone with A-Fib is supposed to be on an anticoagulant for life.
In addition, Dr. Gregory Lip, who was instrumental in developing the CHA2DS2-VASc guidelines, states that even a risk factor of 0 can “identify those who would still substantially benefit from oral anticoagulation.”
In other words, even those with a risk factor of 0 may be put on anticoagulants. (Really?)
Gender as a Risk of Stroke: In the Guidelines, a woman with A-Fib is automatically given one point on the stroke risk scale simply because of being female, no matter how healthy she may be otherwise. (“Sc” stands for sex i.e., female gender.)
(I find that this is not justified by research; Is this a not-very-subtle form of gender bias? See my post: Israeli Study Contradicts Recent CHA2DS2-VASc Guidelines.)
The Exception: controlled Hypertension: If you have hypertension which is controlled (by for example taking a drug like lisinopril) and is under 140/90, you are not considered to have a risk factor for stroke.
Anticoagulants are High Risk Drugs
Unlike what you hear in today’s advertising, anticoagulants are not like taking vitamins. They work by increasing your risk of bleeding. The Guidelines do not discuss that “Oral anticoagulants are high risk medications.”
Dr. John Day describes his patient (and personal friend) Bob who, was on anticoagulation for 10 years. Basically he became a vegetable with early dementia. He remained on an anticoagulant even though he had been A-Fib free after a catheter ablation. (Read the story in my post: The Risks of Life-Long Anticoagulation Therapy)
But because of these guidelines, many more people will be put on anticoagulants, particularly women, and develop other health problems. (Read more: Anticoagulants Increase Risk of Hemorrhagic-Type Strokes ).
Added Motivation to Prescribe Anticoagulants
One of the reasons doctors prescribe anticoagulants at the drop of a hat is the risk of a malpractice lawsuit.
The Guidelines are “in effect” dictates. If a doctor doesn’t follow these guidelines, and a patient has a stroke, that doctor is almost guaranteed a losing malpractice lawsuit. The first thing a trial lawyer will point out to an arbitrator or jury is that the doctor didn’t follow current guidelines.
Anticoagulation: Newer Interpretations of the Guidelines
Reflecting the absurdity of one point for female gender, today’s anticoagulation “recommendations” (dictates) are the same for men with 1 point as for women with 2 points.
(It sounds like the writers of the Guidelines recognize their error and bias against women but won’t actually change the guidelines so as not to lose face and acknowledge they were wrong.)
Female Patients: Is Your Doctor Aware of this Modification? Many doctors are not aware of this new interpretation of the guidelines and automatically put women with A-Fib on anticoagulants for life, without regard to anything else.
How Medical Guidelines can Create Pharma Financial Windfall
Medical Guidelines can have an immense impact on the lives of patients. And an immense boost to revenue for the pharmaceutical industry, often overnight.
For instance, in 2017, new guidelines for the management of high blood pressure were issued by the ACC and AHA. The threshold for hypertension was lowered from 140/90 mm Hg (or higher) to 130/80 mm Hg.
Overnight nearly half of US adults were suddenly classified as having hypertension. This means doctors would be prescribing a lot more medications, to a lot more patients. What a boom to the sales of thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers.
This one change in the medical guidelines was a financial windfall for drug companies and represents a huge increase in customers (many for a lifetime). Doctors complained, patients complained, but not the drug companies.
Don’t Just be a Number on a Risk Assessment Tool!
To take an anticoagulant or not (and, if so, which one) is one of the most important decisions you and your doctor will make.
Don’t just be a number on a risk assessment tool. Educate yourself. Become your own best Patient Advocate.
Start with the posts I’ve mentioned above. Arm yourself with an understanding of anticoagulants and your risk of clots and strokes. Then you need to intelligently discuss this decision with your doctor.
