Impact of CHA2DS2VASc Score on Candidacy for Anticoagulation in Patients With Atrial Fibrillation: A Multi-payer Analysis

Published:September 23, 2016DOI:



      The purpose of this study is to report on the effect of using CHA2DS2VASc (congestive heart failure, hypertension, age ≥75 years [doubled], type 1 or type 2 diabetes mellitus, stroke or transient ischemic attack or thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease, or aortic plaque], age 65–75 years, sex category [female]) rather than CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke) to determine candidacy for anticoagulant prophylaxis in insured patients with atrial fibrillation (AF).


      Six administrative claims databases that included medical and pharmacy claims for patients aged ≥18 years with a new or existing diagnosis of AF and patient outcomes assessed for 1 year after diagnosis were analyzed. Retrospective health plan data analyses were performed using a software tool (Anticoagulant Quality Improvement Analyzer). Study measures included stroke risk (identified by CHADS2 and CHA2DS2VASc scores), bleeding risk (identified by the Anticoagulation and Risk Factors in Atrial Fibrillation score), and anticoagulant use.


      A total of 115,906 patients with AF (range of mean ages among the 6 databases, 56–79 years) met the inclusion criteria. All ranges reported represent the minimum and maximum values among the 6 databases. Using the CHA2DS2VASc compared with the CHADS2 index to assess stroke risk resulted in a 23% to 32% increase in patients considered potential candidates for anticoagulant prophylaxis. This translated to a 38% to 114% increase in the number of ostensibly undertreated patients. Among patients with high stroke and low bleeding risk, 18% to 28% more patients were considered potential candidates for anticoagulation treatment using CHA2DS2VASc compared with CHADS2, or a 57% to 151% increase in the number of undertreated patients.


      Use of the CHA2DS2VASc score to determine the risk of stroke increased the number of AF patients for whom oral anticoagulation would be recommended. Additional research is needed to determine whether this paradigm shift to greater use of oral anticoagulants improves patient outcomes.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Therapeutics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 200;285:2370–2375.

        • You J.J.
        • Singer D.E.
        • Howard P.A.
        • et al.
        Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
        Chest. 2012; 141: e531S-e575S
        • Winkle R.A.
        • Mead R.H.
        • Engel G.
        • et al.
        Comparison of CHADS2 and CHA2DS2-VASC anticoagulation recommendations: evaluation in a cohort of atrial fibrillation ablation patients.
        Europace. 2014; 16: 195-201
        • Hart R.G.
        • Pearce L.A.
        • Aguilar M.I.
        Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.
        Ann Intern Med. 2007; 146: 857-867
        • Kakkos S.K.
        • Kirkilesis G.I.
        • Tsolakis I.A.
        Efficacy and safety of the new oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban in the treatment and secondary prevention of venous thromboembolism: a systematic review and meta-analysis of phase III trials.
        Eur J Vasc Endovasc Surg. 2014; 48: 565-575
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • et al.
        2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        J Am Coll Cardiol. 2014; 64: 2246-2280
        • Lakshminarayan K.
        • Solid C.A.
        • Collins A.J.
        • et al.
        Atrial fibrillation and stroke in the general Medicare population: a 10-year perspective (1992 to 2002).
        Stroke. 2006; 37: 1969-1974
        • Goto S.
        • Bhatt D.L.
        • Röther J.
        • et al.
        Prevalence, clinical profile, and cardiovascular outcomes of atrial fibrillation patients with atherothrombosis.
        Am Heart J. 2008; 156: 855-863
        • Ogilvie I.M.
        • Newton N.
        • Welner S.A.
        • et al.
        Underuse of oral anticoagulants in atrial fibrillation: a systematic review.
        Am J Med. 2010; 123: 638-645
        • Zimetbaum P.J.
        • Thosani A.
        • Yu H.-T.
        • et al.
        Are atrial fibrillation patients receiving warfarin in accordance with stroke risk?.
        Am J Med. 2010; 123: 446-453
        • Fuster V.
        • Rydén L.E.
        • Cannom D.S.
        • et al.
        2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2011; 123: e269-e367
        • Camm A.J.
        • Kirchhof P.
        • Lip G.Y.H.
        • et al.
        Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC).
        Eur Heart J. 2010; 31: 2369-2429
        • Gage B.F.
        • Waterman A.D.
        • Shannon W.
        • et al.
        Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.
        JAMA. 2001; 285: 2864-2870
        • Lip G.Y.
        • Niewlaat R.
        • Pisters R.
        • et al.
        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: 263-272
        • Lang K.
        • Federico V.
        • Patel A.A.
        • et al.
        Antithrombotic use and bleeding risk in patients with atrial fibrillation: findings from a multipayer analysis.
        J Comp Eff Res. 2016; 5: 39-48
        • Gitlin M.
        • Lee J.A.
        • Spiegel D.M.
        • et al.
        Outpatient red blood cell transfusion payments among patients on chronic dialysis.
        BMC Nephrol. 2012; 13: 145
        • Yiee J.H.
        • Saigal C.S.
        • Lai J.
        • et al.
        Timing of orchiopexy in the United States: a quality-of-care indicator.
        Urology. 2012; 80: 1121-1126
        • Fang M.C.
        • Go A.S.
        • Chang Y.
        • et al.
        A new risk scheme to predict warfarin-associated hemorrhage: The ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study.
        J Am Coll Cardiol. 2011; 58: 395-401
        • O’Brien E.C.
        • Kim S.
        • Hess P.L.
        • et al.
        Effect of the 2014 atrial fibrillation guideline revisions on the proportion of patients recommended for oral anticoagulation.
        JAMA Intern Med. 2015; 175: 848-850