CHA₂DS₂-VASc or CHA₂DS₂-VA? What changed with the 2024 ESC guideline
CHA₂DS₂-VA is CHA₂DS₂-VASc without the point for female sex, and the 2024 ESC atrial fibrillation guideline adopted it in place of the older score. Treatment decisions are almost unchanged. What changes is how you read the number.
At a glance
| CHA₂DS₂-VASc | CHA₂DS₂-VA | |
|---|---|---|
| Introduced | 2010 (Lip et al.) | Adopted by the ESC in 2024 |
| Items | 8 categories, including sex | 7 categories, sex removed |
| Maximum score | 9 | 8 |
| Female sex | +1 point | No point |
| Thresholds | Different for men and women | One set for everyone |
| Used by | ACC/AHA 2023, earlier ESC guidelines, many local documents | ESC 2024 |
The arithmetic is simple: CHA₂DS₂-VA = CHA₂DS₂-VASc minus the sex point. For men the two scores are identical; for women CHA₂DS₂-VA is one point lower.
The items, side by side
| Letter | Risk factor | Points |
|---|---|---|
| C | Congestive (chronic) heart failure | 1 |
| H | Hypertension | 1 |
| A₂ | Age 75 or over | 2 |
| D | Diabetes mellitus | 1 |
| S₂ | Prior stroke, TIA or thromboembolism | 2 |
| V | Vascular disease (prior myocardial infarction, peripheral arterial disease, aortic plaque) | 1 |
| A | Age 65–74 | 1 |
| Sc | Sex category: female | 1 (CHA₂DS₂-VASc only) |
The DoseStep CHA₂DS₂-VASc calculator asks for every item (age is a single question), shows the CHA₂DS₂-VASc total, and reports the CHA₂DS₂-VA value next to it; its risk band is based on CHA₂DS₂-VA.
Why was the sex point removed?
CHA₂DS₂-VASc gave a point to women because, in the cohorts available in the 2000s, women with atrial fibrillation had more strokes than men. Later, larger registry analyses showed a more nuanced picture. In a Danish nationwide study, Nielsen and colleagues found that female sex added little or no risk when no other risk factor was present, and increased risk mainly in older people and in combination with other factors. In other words, sex behaves as a risk modifier rather than an independent risk factor.
That had a practical consequence. Because a woman automatically started at 1, guidelines needed separate thresholds for men and women: a score of 1 meant “some risk” in a man but “no additional risk” in a woman. This was a well-known source of confusion.
The 2024 ESC guideline gave three main reasons for dropping the point:
- Simplicity: one score and one set of thresholds for everyone.
- Accuracy: the sex point added little to risk prediction once the other factors were counted.
- Inclusivity: it avoids having to assign a sex category, for example in transgender or non-binary people or those on gender-affirming hormone therapy.
What changes in the thresholds
| Stroke risk decision | ESC 2020 (CHA₂DS₂-VASc) | ESC 2024 (CHA₂DS₂-VA) | ACC/AHA 2023 (CHA₂DS₂-VASc) |
|---|---|---|---|
| Anticoagulation generally not indicated | 0 in men, 1 in women | 0 | 0 in men, 1 in women |
| Anticoagulation should be considered / is reasonable | 1 in men, 2 in women | 1 | 1 in men, 2 in women (1–2% a year) |
| Anticoagulation recommended | ≥ 2 in men, ≥ 3 in women | ≥ 2 | ≥ 2 in men, ≥ 3 in women (≥ 2% a year) |
Read across a row and the decision boundaries are the same. The 2024 change is mainly about how the number is expressed, not a new set of patients being treated. The ESC also stresses that the score is only a starting point: other factors that raise stroke risk, and the patient’s own values, are part of the decision.
Worked examples
Each example gives both scores, calculated exactly as the site’s calculator does.
| Patient | Points counted | CHA₂DS₂-VASc | CHA₂DS₂-VA | Band (ESC 2024) |
|---|---|---|---|---|
| Woman, 62, no other risk factors | Sex 1 | 1 | 0 | Low |
| Man, 62, no other risk factors | None | 0 | 0 | Low |
| Woman, 70, no other risk factors | Age 65–74 1 + sex 1 | 2 | 1 | Intermediate |
| Man, 70, diabetes | Age 65–74 1 + diabetes 1 | 2 | 2 | High |
| Woman, 68, hypertension | Hypertension 1 + age 65–74 1 + sex 1 | 3 | 2 | High |
| Woman, 79, heart failure, prior TIA | Heart failure 1 + age ≥ 75 2 + TIA 2 + sex 1 | 6 | 5 | High |
Two rows show why the old version confused people. The 70-year-old woman and the 70-year-old man with diabetes both score 2 on CHA₂DS₂-VASc, yet under the 2020 ESC thresholds they sat in different categories. With CHA₂DS₂-VA the woman scores 1 and the man 2, and the number alone now tells you the category.
Where CHA₂DS₂-VASc is still used
At the time of writing, the 2023 American College of Cardiology / American Heart Association guideline (with ACCP and HRS) still uses CHA₂DS₂-VASc. It frames thresholds as estimated annual stroke risk and keeps the sex-specific cut-offs. Many national documents, clinical decision support tools, audit forms and published trials also use the older score. In practice you may meet both in the same week:
- A clinic letter that quotes “CHA₂DS₂-VASc 3” for a woman and a European guideline that would call her “CHA₂DS₂-VA 2” describe the same risk.
- When comparing scores between documents, it is advisable to check which version was used.
Whichever version your service uses, the decision for each patient rests with the treating team and the local protocol.
The role of HAS-BLED
Guidelines weigh stroke prevention against the risk of bleeding. HAS-BLED (hypertension, abnormal renal or liver function, stroke, bleeding, labile INR, elderly, drugs or alcohol) is the best-known bleeding score and can be calculated with the HAS-BLED calculator.
The 2024 ESC guideline puts the emphasis on identifying and correcting modifiable bleeding risk factors, such as uncontrolled blood pressure, unnecessary antiplatelet or anti-inflammatory drugs, and excess alcohol. It advises against using a bleeding score on its own to decide whether to start or stop anticoagulation. A high HAS-BLED therefore flags a patient for closer review and follow-up rather than acting as a veto.
Example: a man of 77 with blood pressure persistently above 160 mmHg who also takes an NSAID. CHA₂DS₂-VASc and CHA₂DS₂-VA are both 3 (hypertension 1, age ≥ 75 2). HAS-BLED is also 3 (uncontrolled hypertension, age over 65, NSAID). Two of the three bleeding points are potentially modifiable, which is the kind of finding the score is meant to bring to light.
Anticoagulant dose selection often depends on kidney function, for which the creatinine clearance calculator is available. The guide on eGFR vs creatinine clearance explains why many anticoagulant labels use Cockcroft-Gault.
Common pitfalls
- Mixing versions. Applying the ESC 2024 threshold (≥ 2) to a woman’s CHA₂DS₂-VASc overstates her category by one step.
- Forgetting the age weights. Age 65–74 gives 1 point and age 75 or over gives 2; they are not added together.
- Counting hypertension only if uncontrolled. In CHA₂DS₂-VASc and CHA₂DS₂-VA a history of hypertension counts even when well treated. HAS-BLED, by contrast, counts uncontrolled hypertension.
- Treating a score as a prescription. The scores support a discussion; they do not decide anticoagulation by themselves.
- Using HAS-BLED as a reason to withhold. A high bleeding score is a prompt to address modifiable factors.
- Not re-scoring. Risk factors accumulate with age and new diagnoses; a score from two years ago may be out of date.
Frequently asked questions
What is the difference between CHA₂DS₂-VASc and CHA₂DS₂-VA?
CHA₂DS₂-VA is the same score without the sex category (Sc), which gave one point for female sex. Every other item and its weight is unchanged, so the maximum falls from 9 to 8 points. For a man the two scores are identical; for a woman, CHA₂DS₂-VA is one point lower.
Why was the sex point removed?
Registry data showed that female sex raises stroke risk mainly when other risk factors are present, acting as a risk modifier rather than a risk factor on its own. Removing it lets one set of thresholds apply to everyone and avoids the frequent misreading of a score of 1 in a woman.
Do the treatment thresholds change?
In the 2024 ESC guideline, a CHA₂DS₂-VA of 2 or more marks elevated risk where anticoagulation is recommended, and a score of 1 is a reason to consider it. These map onto the old sex-specific CHA₂DS₂-VASc thresholds, so most decisions are the same.
Do American guidelines use CHA₂DS₂-VA?
No. The 2023 ACC/AHA/ACCP/HRS atrial fibrillation guideline still uses CHA₂DS₂-VASc, with thresholds expressed as annual stroke risk and different cut-offs for men and women. Teams working with different guidelines may therefore quote different numbers for the same patient, so it is advisable to check which version a document uses.
Can I convert CHA₂DS₂-VASc to CHA₂DS₂-VA?
Yes: for a woman, subtract one point; for a man, the two scores are identical. A woman with CHA₂DS₂-VASc 3 has CHA₂DS₂-VA 2. The DoseStep calculator shows both results side by side and bases its risk band on CHA₂DS₂-VA, so you do not need to convert by hand.
Is HAS-BLED still used?
Bleeding risk is still assessed, but the 2024 ESC guideline emphasises finding and correcting modifiable bleeding risk factors and advises against using a bleeding score alone to start or withhold anticoagulation. HAS-BLED remains a common way to structure that review.
Sources
- Van Gelder IC et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2024;45:3314–3414
- Nielsen PB et al. Female sex is a risk modifier rather than a risk factor for stroke in atrial fibrillation: should we use a CHA₂DS₂-VA score rather than CHA₂DS₂-VASc? Circulation 2018;137:832–840
- Joglar JA et al. 2023 ACC/AHA/ACCP/HRS Guideline for the diagnosis and management of atrial fibrillation. Circulation 2024;149:e1–e156
- Lip GY 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
- Pisters R et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010;138:1093–1100