Comparison of CHADS(2) and CHA(2)DS(2)-VAS(C) anticoagulation recommendations: evaluation in a cohort of atrial fibrillation ablation patients

AIMS: Atrial fibrillation (AF) is associated with a high incidence of strokes/thromboembolism. The CHADS(2) score assigns points for several clinical variables to identify stroke risk. The CHA(2)DS(2)-VAS(C) score uses the same variables but also incorporates age 65 to 74, female gender, and vascular disease in an effort to provide a more refined risk of stroke/thromboembolism. We aimed to examine oral anticoagulation (OAC) recommendations for a cohort of patients undergoing AF ablation depending upon whether thrombo-embolic risk was determined by the CHADS(2) or CHA(2)DS(2)-VAS(C) score. METHODS AND RESULTS: For 1411 patients we compared OAC recommendations for each of these risk stratification schemes to one of the three OAC strategies: (i) NO-OAC, (ii) CONSIDER-OAC, and (iii) DEFINITE-OAC. Compared with the CHADS(2) score, the CHA(2)DS(2)-VAS(C) score reduced NO-OAC from 40.3 to 21.8% and CONSIDER-OAC from 36.6 to 27.9% while increasing DEFINITE-OAC from 23.0 to 50.2% of patients. Age 65 to 74 and female gender accounted for 95.2% and vascular disease for only 4.8% of recommendations for more aggressive OAC using CHA(2)DS(2)-VAS(C). Most vascular disease occurred in patients with higher CHADS(2) scores already recommended for DEFINITE-OAC (P < 0.0001). Reclassifying 30 females of age <65 with a CHA(2)DS(2)-VAS(C) score of 1 to the NO-OAC group had minimal effect on the overall recommendations. CONCLUSION: Compared with the CHADS(2) score, in our AF ablation population, the CHA(2)DS(2)-VAS(C) score markedly increases the number of AF patients for whom OAC is recommended. It will be important to determine by randomized trials if this major paradigm shift to greater use of OAC using the CHA(2)DS(2)-VAS(C) scoring improves patient outcomes.