Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

The CHADS₂ score is widely used to estimate stroke risk in individuals with atrial fibrillation by evaluating five specific risk factors. Each factor contributes a designated number of points, and their combined total offers an assessment of stroke likelihood.

For the CHADS₂ score calculation, consider the following risk factors, each assigned a set point value:

- Age 75 years or older: 1 point
- Hypertension: 1 point
- Diabetes mellitus: 1 point
- Congestive heart failure: 1 point
- History of stroke or transient ischemic attack: 2 points

To compute the score, determine if each condition is present. Assign points based on the presence (true) of these conditions and sum the points for a total score ranging from 0 to 6. This total score then assists health professionals in the decision-making process regarding anticoagulation therapy.

Once you have the total score, assess the risk of stroke by interpreting the score as follows:

- If the score is 0, the annual stroke risk is approximately 1.9%.
- A score of 1 equates to a 2.8% risk.
- A score of 2 suggests a 4.0% risk.
- A score of 3 indicates a 5.9% risk.
- A score of 4 corresponds to an 8.5% risk.
- A score of 5 translates to a 12.5% risk.
- A score of 6 represents an 18.2% risk.

This scoring system not only provides a numeric assessment but also aids in evaluating the necessity of preventive treatment to reduce stroke risk in patients with atrial fibrillation.

The CHADS₂ score is a clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation (AF), a common and serious heart rhythm disturbance. This score is simple and has been validated by many studies in different groups of AF patients. 

The CHADS₂ acronym stands for Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, and prior Stroke or transient ischemic attack (TIA). Each factor scores one point, except for prior stroke or TIA, which scores two points. The total score ranges from 0 to 6, with higher scores indicating a greater risk of stroke.

The clinical utility of the CHADS₂ score is to help clinicians decide whether or not to anticoagulate a patient with AF. Patients with a score of 0 are at low risk and do not require anticoagulation. Patients with a score of 1 can be considered for anticoagulation, and those with a score of 2 or more should definitely be anticoagulated, unless contraindicated.

The CHADS₂ score should not be used in patients with rheumatic AF, valvular heart disease, or those who have a contraindication to antico

CHADS₂ score for stroke risk in atrial fibrillation

The CHA₂DS₂-VASc score is a tool used to estimate the risk of stroke in individuals with atrial fibrillation. It assigns points based on various risk factors, and the total score guides clinical decisions regarding anticoagulation therapy.

Here’s how the scoring works:

- Age:
  - Below 65 years scores 0 points.
  - Between 65 and 74 years scores 1 point.
  - 75 years or older scores 2 points.

- Sex:
  - Female scores 1 point.
  - Male scores 0 points.

- Hypertension:
  - If present, scores 1 point.
  - If absent, scores 0 points.

- Diabetes Mellitus:
  - If present, scores 1 point.
  - If absent, scores 0 points.

- Congestive Heart Failure/Left Ventricular Dysfunction:
  - If present, scores 1 point.
  - If absent, scores 0 points.

- History of Stroke/Thromboembolism/Transient Ischemic Attack:
  - If present, scores 2 points.
  - If absent, scores 0 points.

- History of Vascular Disease (such as prior myocardial infarction or peripheral artery disease):
  - If present, scores 1 point.
  - If absent, scores 0 points.

To calculate the score, assess each of these factors for the individual and sum the respective points.

Once the total score is determined, it is interpreted as follows:
- A score of 0 implies a 0.2% risk of ischemic stroke and a 0.3% risk of stroke/transient ischemic attack/systemic embolism.
- A score of 1 indicates a 0.6% risk of ischemic stroke and a 0.9% risk of stroke/TIA/systemic embolism.
- A score of 2 suggests a 2.2% risk of ischemic stroke and a 2.9% risk of stroke/TIA/systemic embolism.
- A score of 3 means a 3.2% risk of ischemic stroke and a 4.6% risk of stroke/TIA/systemic embolism.
- A score of 4 reveals a 4.8% risk of ischemic stroke and a 6.7% risk of stroke/TIA/systemic embolism.
- A score of 5 corresponds to a 7.2% risk of ischemic stroke and a 10.0% risk of stroke/TIA/systemic embolism.
- A score of 6 represents a 9.7% risk of ischemic stroke and a 13.6% risk of stroke/TIA/systemic embolism.
- A score of 7 reflects an 11.2% risk of ischemic stroke and a 15.7% risk of stroke/TIA/systemic embolism.
- A score of 8 implies a 10.8% risk of ischemic stroke and a 15.2% risk of stroke/TIA/systemic embolism.
- A score of 9 equates to a 12.2% risk of ischemic stroke and a 17.4% risk of stroke/TIA/systemic embolism.

This comprehensive scoring system helps identify the stroke risk and aids healthcare providers in making informed decisions about patient care.

The CHA₂DS₂-VASc score is a clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation (AF). The acronym stands for Congestive heart failure, Hypertension, Age ≥75 years (doubled), Diabetes mellitus, Stroke (doubled), Vascular disease, Age 65–74 years, and Sex category (female). Each factor is assigned a certain number of points, and the total score is used to estimate the risk of stroke. 

This calculator is specifically applicable to patients with non-rheumatic atrial fibrillation, including those who are being considered for anticoagulation therapy. The clinical utility of the CHA₂DS₂-VASc score is to guide clinicians in making decisions about anticoagulation therapy, as higher scores indicate a greater risk of stroke and may warrant more aggressive treatment.

The CHA₂DS₂-VASc score should not be used in patients with rheumatic atrial fibrillation, as the risk factors and stroke risk in these patients are different. It is also not applicable to patients with transient causes of atrial fibrillation, such as those due to a reversible cause like surgery or acute illness.

CHA₂DS₂-VASc score for stroke risk in atrial fibrillation

The calculator categorizes the severity of heart failure using the New York Heart Association (NYHA) functional classification system. It does this by analyzing a patient's reported physical abilities related to cardiac disease and matches them to one of the four NYHA classes.

Here's the breakdown of each class:

- Class I involves patients who have cardiac disease but do not experience any limitations in physical activity. Regular activities do not cause undue fatigue, palpitation, or shortness of breath.
  
- Class II fits patients who have a slight limitation in physical activity due to cardiac disease. They feel comfortable when at rest, but ordinary physical activities might lead to fatigue, palpitation, or breathlessness.
  
- Class III describes patients with a marked limitation in physical activity. These individuals are comfortable when resting, but even less than ordinary activities cause fatigue, palpitations, breathlessness, or chest pain.
  
- Class IV covers patients who cannot engage in any physical activity without experiencing discomfort. They exhibit symptoms of heart failure even when at rest, and any physical activity worsens these symptoms.

To determine the appropriate class for a patient, the calculator compares the user’s description of their physical ability with these four established patterns. Each condition is linked specifically to one of the NYHA classes, providing a clear pathway from symptom description to classification. For example, if a patient’s physical condition matches the criteria for Class I, then the result is "Class I." This comparison method efficiently identifies the level of heart failure severity based on self-reported abilities and symptoms.

The NYHA functional classification for heart failure, or New York Heart Association Functional Classification, is a scoring system used to quantify the severity of symptoms in patients with heart failure. This classification system is applicable to patients diagnosed with heart failure and is used to assess their functional capacity and limitations during physical activity. 

The NYHA classification is divided into four classes: Class I (no symptoms and no limitation in ordinary physical activity), Class II (mild symptoms and slight limitation during ordinary activity), Class III (marked limitation in activity due to symptoms, even during less-than-ordinary activity), and Class IV (severe limitations, experiences symptoms even while at rest).

The clinical utility of this calculator is to guide treatment decisions, assess prognosis, and evaluate the effectiveness of therapeutic interventions in patients with heart failure. It is also commonly used in clinical trials to stratify patients and measure outcomes. 

There are no specific exclusion criteria for its use, but it is subjective and relies on patient self-report, so it may not be as accurate in patients with cognitive impairment or communication difficulties.

NYHA functional classification for heart failure

Hypertrophic cardiomyopathy

Follow-up

Follow-up, cardiac MRI

Cardiopulmonary exercise testing

Cardiac computed tomography

Cardiac CT

Management of heart failure with preserved ejection fraction

Management of HFpEF

Electrocardiogram

As per ACC/AHA/AMSSM/…/SCMR 2024 guidelines, 

Screening of family relatives

Screening of family relatives, counseling

Medications to avoid

Management of heart failure with reduced ejection fraction

Management of HFrEF

Management of chest pain

Lifestyle modifications

Indications for implantable cardioverter-defibrillator implantation

Indications for ICD implantation, post cardiac arrest

Transthoracic echocardiogram

Evaluation of unexplained syncope

Athletes

Athletes, return to sport

Indications for ICD implantation, pediatric patients

History and physical examination

Management of obstructive symptoms

Management of obstructive symptoms, diuretics

Cardiac catheterization

Physical activity restrictions

Laboratory tests

Screening of family relatives, follow-up

Septal reduction therapy

Septal reduction therapy, surgical myectomy

Coronary angiography

Catheter ablation

Catheter ablation, ventricular arrhythmia

Catheter ablation, AF

Indications for ICD implantation, general principles

Heart transplantation

Management of atrial fibrillation

Management of AF, catheter ablation

Management of obstructive symptoms, medications to avoid

Transesophageal echocardiogram

Patients undergoing noncardiac surgery

Indications for ICD implantation, 4-6% risk of SCD

Management of obstructive symptoms, vasoconstrictors

Left ventricular assist device

LV assist device

Management of obstructive symptoms, disopyramide

Evaluation for coronary artery disease

Screening of family relatives (ECG)

Screening of family relatives (echocardiography)

Apical myectomy

Implantable loop recorder

Mitral valve repair

Screening of family relatives, genetic testing

Follow-up, ECG and TTE

Screening of family relatives (cardiac MRI)

Septal reduction therapy (preoperative coronary angiography)

Antiarrhythmic drugs

Psychological support

Management of obstructive symptoms, beta-blockers and CCBs

Technical considerations for implantable cardioverter-defibrillator implantation

Technical considerations for ICD implantation

Sudden cardiac death risk assessment

SCD risk assessment

Septal reduction therapy (alcohol septal ablation)

Electrophysiological study

General principles

Genetic testing

Indications for ICD implantation, >= 6% risk of SCD

Cardiac magnetic resonance imaging

Cardiac MRI

Ambulatory electrocardiogram monitoring

Ambulatory ECG monitoring

Management of AF, antithrombotic therapy

Follow-up, exercise testing

Pediatric patients

Indications for referral

Indications for ICD implantation, < 4% risk of SCD

Transition to adult care

Pregnant patients

Updated 2024 AHA/ACC guidelines for the diagnosis and management of hypertrophic cardiomyopathy


Hypertrophic cardiomyopathy

Background

Overview

Guidelines

Key sources