The interpretation of CHA2DS2-VA score components in clinical practice: Data from Türkiye

Abstract

Purpose: Atrial fibrillation (AF) is associated with an increased risk of stroke, necessitating accurate risk stratification using validated tools such as the CHA2DS2-VA score. Despite its widespread use, variability exists in clinicians’ interpretation and application of its components. To assess the understanding, interpretation, and practical application of the “C” (congestive heart failure/left ventricular systolic dysfunction), “H” (hypertension), “D” (diabetes mellitus), and “V” (vascular disease) components of the CHA2DS2-VA score among clinicians in Türkiye, and to identify potential educational and informational needs.
Materials and methods: Between July 15 and September 15, 2025, an online survey consisting of 10 multiple-choice questions was administered to physicians via WhatsApp. A total of 197 complete responses were analyzed. The survey assessed knowledge of component definitions, scoring practices, ease of application, and resources used for calculation.
Results: Recognition was highest for the “D” criterion, while the “H” component showed moderate agreement. The “C” and particularly the “V” components demonstrated greater heterogeneity, including under-recognition of aortic aneurysm and misclassification of angina pectoris and varicose veins. Clinicians primarily relied on memory (46.7%) or online resources (38.6%), with 26.9% using web-based or mobile applications. Scoring ease varied, with the “V” criterion rated as most difficult.
Conclusion: Clinicians are generally familiar with the CHA2DS2-VA score, but interpretation of heart failure and vascular disease components is inconsistent. Targeted education, clearer operational definitions, and integration of validated risk calculators into electronic health records and mobile platforms may improve scoring accuracy, consistency, and stroke risk assessment in AF patients.

Keywords

• Atrial fibrillation
• CHA2DS2-VA score
• stroke risk
• risk stratification
• clinician survey

Thanks

We would like to thank Prof. Tatjana S. Potpara for her assistance with the survey questions.

CHA₂DS₂-VA skoru bileşenlerinin klinik uygulamadaki yorumlanması: Türkiye verileri

Abstract

Amaç: Atriyal fibrilasyon (AF), artmış inme riski ile ilişkili olup, riskin doğru değerlendirilmesi için CHA2DS2-VA skoru gibi geçerliliği kanıtlanmış skor sistemlerinin kullanımı gereklidir. Ancak bu skorun bileşenlerinin klinisyenler tarafından yorumlanmasında ve uygulanmasında farklılıklar gözlenmektedir. Bu çalışmada, Türkiye’deki klinisyenlerin CHA2DS2-VA skorunun “C” (konjestif kalp yetersizliği/sol ventrikül sistolik disfonksiyonu), “H” (hipertansiyon), “D” (diyabetes mellitus) ve “V” (vasküler hastalık) bileşenlerine ilişkin bilgi, yorum ve uygulama düzeylerinin değerlendirilmesi ile eğitim ve bilgilendirme ihtiyaçlarının belirlenmesi amaçlandı.
Gereç ve yöntem: 15 Temmuz - 15 Eylül 2025 tarihleri arasında hekimlere WhatsApp üzerinden 10 adet çoktan seçmeli sorudan oluşan çevrimiçi anket uygulandı ve 197 adet geçerli yanıt analiz edildi. Anket, bileşen tanımlarına ilişkin bilgi düzeyi, skorlama uygulamaları, kullanım kolaylığı ve hesaplama için kullanılan kaynakları değerlendirdi.
Bulgular: En yüksek doğru yanıt oranı “D” bileşeninde elde edilirken, “H” orta düzeyde, “C” ve özellikle “V” bileşenlerinde ise belirgin heterojenlik saptandı. Aort anevrizması sıklıkla gözden kaçarken, anjina pektoris ve varisler yanlış sınıflandırıldı. Katılımcıların %46,7’si skoru hafızadan, %38,6’sı çevrimiçi kaynaklardan, %26,9’u ise mobil veya web tabanlı uygulamalardan hesapladı. Puanlama zorluğu açısından “V” kriteri en zorlu bileşen olarak değerlendirildi.
Sonuç: Klinisyenler CHA2DS2-VA skoruna genel olarak aşina olmakla birlikte, özellikle kalp yetersizliği ve vasküler hastalık bileşenlerinin yorumlanmasında farklılıklar mevcuttur. Daha net tanımlar, hedefe yönelik eğitim programları ve doğrulanmış risk hesaplayıcılarının elektronik sağlık kayıtları ile mobil platformlara entegrasyonu, skorlamanın doğruluğunu ve tutarlılığını artırabilir, AF hastalarında inme risk değerlendirmesini iyileştirebilir.

Keywords

• Atriyal fibrilasyon
• CHA2DS2-VA skoru
• inme riski
• risk sınıflandırması
• klinisyen anketi

Thanks

Anket sorularında yardımları için Prof. Tatjana S. Potpara'ya teşekkür ederiz.

References

1. Li H, Song X, Liang Y, et al. Global, regional, and national burden of disease study of atrial fibrillation/flutter, 1990-2019: results from a global burden of disease study, 2019. BMC Public Health. 2022;22(1):2015. doi:10.1186/s12889-022-14403-2
2. Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024;45(36):3314-3414. doi:10.1093/eurheartj/ehae176
3. Borre ED, Goode A, Raitz G, et al. Predicting Thromboembolic and Bleeding Event Risk in Patients with Non-Valvular Atrial Fibrillation: A Systematic Review. Thromb Haemost. 2018;118(12):2171-2187. doi:10.1055/s-0038-1675400
4. Zhang J, Lenarczyk R, Marin F, et al. The interpretation of CHA2DS2-VASc score components in clinical practice: a joint survey by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, the EHRA Young Electrophysiologists, the Association of Cardiovascular Nursing and Allied Professionals, and the European Society of Cardiology Council on Stroke. Europace. 2021;23(2):314-322. doi:10.1093/europace/euaa358
5. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. 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(2):263-272. doi:10.1378/chest.09-1584
6. Kirchhof P, Benussi S, Kotecha D. ESC Guidelines for the diagnosis and management of atrial fibrillation. Eur Heart J. 2020;42(5):373-498.
7. Lip GY, Laroche C, Popescu MI, et al. Improved outcomes with European Society of Cardiology guideline-adherent antithrombotic treatment in high-risk patients with atrial fibrillation: a report from the EORP-AF General Pilot Registry. Europace. 2015;17(12):1777-1786. doi:10.1093/europace/euv269
8. Nielsen PB, Overvad TF. Female Sex as a Risk Modifier for Stroke Risk in Atrial Fibrillation: Using CHA2DS2-VASc versus CHA2DS2-VA for Stroke Risk Stratification in Atrial Fibrillation: A Note of Caution. Thromb Haemost. 2020;120(6):894-898. doi:10.1055/s-0040-1710014

9. Nieuwlaat R, Olsson SB, Lip GY, et al. Guideline-adherent antithrombotic treatment is associated with improved outcomes compared with undertreatment in high-risk patients with atrial fibrillation. The Euro Heart Survey on Atrial Fibrillation. Am Heart J. 2007;153(6):1006-1012. doi:10.1016/j.ahj.2007.03.008
10. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373-498. doi:10.1093/eurheartj/ehaa612
11. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e167. Doi:
12. Lip GYH, Banerjee A, Boriani G, et al. Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report. Chest. 2018;154(5):1121-1201. doi:10.1016/j.chest.2018.07.040
13. Hwang C. (n.d.). CHA2DS2-VASc score for atrial fibrillation stroke risk. MDCalc. Available at: https://www.mdcalc.com/calc/801/cha2ds2-vasc-score-atrial-fibrillation-stroke-risk. Accessed September 7, 2025
14. QxMD (2015, Sep 1). CHA2DS2-VASc score for AF. Calculate by QxMD. Available at: https://qxmd.com/calculate/calculator_41/cha2ds2-vasc-score-for-af. Accessed September 7, 2025