Clinical implications of the recalibrated CHA₂DS₂-VA score for women after ischemic stroke: a prospective cohort study.

Abstract

Introduction: The 2024 ESC atrial fibrillation guidelines introduced the CHA₂DS₂-VA score by removing female sex as an independent risk criterion. Although intended to simplify risk stratification and avoid sex-based overtreatment, the real-world implications for women who present with AF-related ischemic stroke/TIA remain unclear. In this prospective observational study, we examined the clinical implications of CHA₂DS₂-VA recalibration in a post-stroke setting, focusing on sex-specific differences in stroke severity and early functional outcome, and on the proportion of women who newly fall below the anticoagulation threshold (score ≤ 1).

Methods: In a prospective cohort of 714 consecutive stroke patients, 161 (22.5%) had documented AF. Risk stratification was performed using both CHA₂DS₂-VASc and the revised CHA₂DS₂-VA score. Stroke severity (NIHSS) and functional outcome (mRS) were analyzed by sex. Propensity score matching and multivariable logistic regression were used to examine the independent association between sex and stroke severity.

Results: Female patients with AF were older and had a higher vascular risk burden than men. They presented with significantly more severe strokes (median NIHSS 12 vs. 8; P < 0.01) and tended toward worse outcomes. After score recalibration, 11 of 81 women (13.6%) had a CHA₂DS₂-VA score ≤ 1, falling below the ESC anticoagulation threshold-despite having experienced an ischemic stroke. Most of these patients had cardioembolic strokes and moderate-to-severe neurological deficits. In matched analyses, female sex remained independently associated with severe stroke (aOR 1.54, 95% CI 1.03-2.29).

Conclusion: In this prospective cohort of AF-related ischemic stroke, women had greater comorbidity burden and higher stroke severity than men. A subgroup with CHA₂DS₂-VA ≤ 1 nonetheless sustained ischemic stroke, and exploratory 5-year follow-up suggested excess recurrence without anticoagulation. These findings require validation in larger cohorts.