Decision
CHA2DS2-VASc 0 or 1 ?
Yes
Discharge with 4 weeks of oral anticoagulation (Class I)
No
Perform synchronized cardioversion (Class I) with sedation
Background
CHA2DS2-VASc Score
Risk Factor | Points |
Congestive heart failure, left ventricular dysfunction | 1 |
Hypertension | 1 |
Age >75 years | 2 |
Diabetes | 1 |
Prior stroke/transient ischemic attack | 2 |
Vascular disease | 1 |
Age 65-74 years | 1 |
Sex: female | 1 |
Assessing risk of bleeding due to anticoagulation:
“The benefit of anticoagulation must always be weighed against the risk for bleeding. HAS-BLED is a validated score for risk for bleeding.82 (See Tables 6 and 7.) A score ≥3 indicates a high risk for bleeding and correlates with 3.74 bleeds per 100 patient-years. Although a high score by HAS-BLED is associated with an increased risk for bleeding, it is not a contraindication to starting an oral anticoagulant; bleeding risk factors should be identified by using a score, and modifiable factors should be addressed”1
HAS-BLED Score
Risk Factor | Points |
Hypertension | 1 |
Abnormal renal and liver function (1 point for each) | 1 or 2 |
Stroke | 1 |
Bleeding | 1 |
Labile INR | 1 |
Elderly (age >65 years) | 1 |
Drugs or alcohol (1 point for each) | 1 or 2 |
Risk Score | Bleeds Per 100 Patient-Years | Risk % | Risk for Bleeding |
0 | 1.13 | 0.9% | Low |
1 | 1.02 | 3.4% | Moderate |
2 | 1.88 | 4.1% | Moderate |
3 | 3.74 | 5.8% | High |
4 | 8.70 | 8.9% | High |
5 | 12.50 | 9.1% | High |
References:
- Milman B, Burns BD. Atrial fibrillation: an approach to diagnosis and management in the emergency department. Emerg Med Pract. 2021 May;23(5):1-28. Epub 2021 May 1. PMID: 33885254.
- Pisters R, Lane DA, Nieuwlaat 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(5):1093-1100. (Retrospective cohort; 3978 patients)
- Lip GY, Frison L, Halperin JL, Lane DA. Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol. 2011 Jan 11;57(2):173-80. doi: 10.1016/j.jacc.2010.09.024. Epub 2010 Nov 24.
