Copy of Snippet "CHA2DS2-VASc"

CHA2DS2-VASc Calculator inspired by MDcalc. Entering the shortcut will prompt you to answer the questions necessary for scoring. The calculator will create a score for you based on your answers, and you can check/uncheck a box that will append the score to your note at the point of the cursor. More information on the score and how to interpret can be expanded in the pop-up window for your review.

(Note: Most of the pop-up window triggered by the shortcut is a note and will not be entered into your note when you hit insert. The only output that would come from the output would be the score; the rest is just for your reference. You'll have to try it to see what I mean.)

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{note}CHA2DS2-VASc Score Calculation
The CHA2DS2-VASc score is one of several risk stratification schema that can help determine the 1 year risk of a TE event in a non-anticoagulated patient with non-valvular AF.
The CHA2DS2-VASc score, among other risk stratification schema, can be used to provide an idea of a patient’s risk for TE event.


Answer the following questions based on the initial evaluation of the patient's history:

Questions Response
Age? {formmenu: default=\<\6\5; \6\5\-\7\4; \≥\7\5; name=age}
Sex? {formmenu: Female; default=Male; name=sex}
Congestive Heart Failure History? {formmenu: Yes; default=No; name=chf; trim=no}
Hypertension History? {formmenu: Yes; default=No; name=htn; trim=no}
Stroke/TIA/Thromboembolism History? {formmenu: Yes; default=No; name=stiate; trim=no}
Vascular Disease History? (prior MI, peripheral artery disease, or aortic plaque) {formmenu: Yes; default=No; name=vdh; trim=no}
Diabetes History? {formmenu: Yes; default=No; name=dmh; trim=no}
{if: age="<65"; trim=yes}{a1=0}{elseif: age="65-74"}{a1=1}{else}{a1=2}{endif}
{if: sex="Female"; trim=yes}{sc=1}{else}{sc=0}{endif}
{if: chf="Yes"; trim=yes}{hf=1}{else}{hf=0}{endif}
{if: htn="Yes"; trim=yes}{tn=1}{else}{tn=0}{endif}
{if: stiate="Yes"; trim=yes}{stt=2}{else}{stt=0}{endif}
{if: vdh="Yes"; trim=yes}{vd=1}{else}{vd=0}{endif}
{if: dmh="Yes"; trim=yes}{dm=1}{else}{dm=0}{endif}
Calculated CHA2DS2-VASc Score
{=sum([a1, sc, hf, tn, stt, vd, dm])}
Anticoagulation if CHA2DS2-VASc score of >2 if male or >3 if female
(Refer to "Critical Actions" for special considerations)

Append Score to Note?{endnote}
{formtoggle: name=Yes; default=yes; trim=yes}CHA₂DS₂-VASc Score: {=sum([a1, sc, hf, tn, stt, vd, dm])}{endformtoggle}

{note}
Critical Actions
{formtoggle: name=View Critical Actions (What to do?); default=no}Recent guidelines emphasize the strong evidence of benefit with anticoagulation, and the lack of benefit from antiplatelet treatment. Most guidelines suggest that scores of 0 (men) or 1 (women) do not require treatment; however, all other patients should receive anticoagulation, preferably with a direct oral anticoagulant (unless contraindicated).

Anticoagulation is not recommended in patients with non-valvular AF and a CHA2DS2-VASc score of 0 if male or 1 if female, as these patients had no TE events in the original study.
Depending on a patient’s preferences and individual risk factors, anticoagulation can be considered for a CHA2DS2-VASc score of 1 in males and 2 in females
Anticoagulation should be started in patients with a CHA2DS2-VASc score of >2 if male or >3 if female
For those patients in whom anticoagulation is considered, risk bleeding scores such as ATRIA can be used to determine the risk for warfarin-associated hemorrhage; however, these should usually be used as a reminder to regularly address reversible risk factors for bleeding, as the risk-benefit ratio of anticoagulation usually remains favorable.
Carefully consider all the risks and benefits prior to initiating anticoagulation in patients with non-valvular AF.
Aspirin monotherapy is not supported by current evidence.{endformtoggle}

Further Reading
{formtoggle: name=View Additional Information; default=no}
FROM THE CREATOR
Why did you develop the CHA₂DS₂-VASc score? Was there a clinical experience that inspired you to create this tool for clinicians?
The availability of Non-Vitamin K Antagonist Oral Anticoagulants (NOACs, previously referred to as new or novel oral anticoagulants, has led to a major change in the landscape for stroke prevention in atrial fibrillation (AF). Clinicians are also getting better at understanding how to manage warfarin, recognizing the importance of the average time in therapeutic range (TTR). New data are also re-emerging on the poor evidence for the efficacy and safety of aspirin for stroke prevention in AF. The older CHADS2 Score was designed to identify “high risk” patients for warfarin, but many common (and important) stroke risk factors in AF are not included within the CHADS2. CHA₂DS₂-VASc was developed to be more inclusive of common stroke risk factors/modifiers. Numerous validation studies have shown that CHA2DS2-VASc is as good as - or possibly better - than CHADS2 at predicting high risk patients, but CHA2DS2-VASc is certainly best at predicting the “low risk” patients.
What pearls, pitfalls and/or tips do you have for users of the CHA2DS2-VASc score? Are there cases when it has been applied, interpreted, or used inappropriately?
In older guidelines, the focus was to identify AF patients at ‘high risk’ of stroke, to target for warfarin treatment; however, many studies have shown under-use of warfarin amongst such ‘high risk’ patients. In 2014, the AHA/ACC/HRS guidelines recommended used of the CHA2DS2-VASc score as the stroke risk assessment tool of choice.
How best to approach stroke prevention in AF by using the CHA2DS2-VASc score?
In 2012, the European Society of Cardiology (ESC) guidelines recommended a clinical practice shift, to initially focus on the identification of ‘truly low risk’ patients who do not need any antithrombotic therapy. These low risk patients are those CHA2DS2-VASc score of 0 (male) or 1 (female). Subsequently, the next step is to offer effective stroke prevention (ie. Oral anticoagulation) to those with ≥1 additional stroke risk factors.
What recommendations do you have for health care providers once they have the CHA2DS2-VASc score result? Are there any adjustments or updates you would make to the score given recent changes in medicine?
Use the approach recommended in the 2012 ESC or NICE guidelines - first step, identify LOW RISK patients, i.e., CHA₂DS₂-VASc score of 0 (males) or 1 (females), who do not need any antithrombotic therapy, Next or subsequent step is to offer effective stroke prevention to all others with 1 or more additional stroke risk factors. As per the NICE guidelines, aspirin should not be used for stroke prevention in AF - it is minimally effective, not safe nor is it cost effective.
Have you found colleagues adjusting who receives which type of anticoagulant based on the CHA2DS2-VASc score rather than the CHADS2 alone?
Definitely. A CHADS2 of 0 is NOT low risk, and stroke rate can be as high as 3.2%/year if untreated (Olesen et al, Thromb Haemostat 2012). Using CHA₂DS₂-VASc can further refine stroke risk stratification of those with a CHADS2 score of 0 to identify those who would still substantially benefit from oral anticoagulation.
{endformtoggle}

References:
Courtesy of MDcalc.com
Link: CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk - MDCalc
Author: Dr. Gregory Lip
{endnote}

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