Stroke and bleeding risk in atrial fibrillation: navigating the alphabet soup of risk-score acronyms (CHADS2, CHA2DS2-VASc, R2CHADS2, HAS-BLED, ATRIA, and more)

Abstract

Stroke prevention is central to the management of patients with atrial fibrillation (AF). As effective stroke prophylaxis essentially requires oral anticoagulants (OAC) an understanding of the risks and benefits of OAC therapy is needed. While AF increases stroke risk 5-fold, this risk is not homogeneous. Many stroke risk factors also confer an increased risk of bleeding. Various stroke and bleeding risk stratification schemes have been developed to help inform clinical decision making. These scores were derived and validated in different study cohorts, ranging from highly selected clinical trial cohorts to 'real world' populations. Thus, their performance and classification accuracy varies depending on their derivation cohort(s). In the present review, we provide an overview of currently available stroke and bleeding risk stratification schemes. We particularly focus on the CHA2DS2-VASc and HAS-BLED schemes, as these are recommended by the latest European guidelines on AF management. Other risk stratification schemes (CHADS2, R2CHADS2, ATRIA, HEMORRHAGES, QStroke, etc.) and their place in the decision-making are also considered.