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Practice Question: CHA₂DS₂-VASc Score AF · This Is Why with Dr. Busti

• 0:00
  SPEAKER_00: Welcome to this episode on a practice test question where I'm gonna break down a high-yield multiple choice question on one of the most tested concepts related and about the management of atrial fibrillation.
• 0:13
  SPEAKER_00: That is understanding the Chad's vast score and recognizing when anticoagulation should or should not be initiated.
• 0:23
  SPEAKER_00: Hey guys, I'm Dr.
• 0:24
  SPEAKER_00: Bustaye.
• 0:25
  SPEAKER_00: Thank you so much for joining.
• 0:27
  SPEAKER_00: This is why, a show dedicated to helping healthcare professionals transform their medical knowledge from what to why, because that improves the how.
• 0:36
  SPEAKER_00: And the how here is about tackling multiple choice questions on your exams and boards.
• 0:44
  SPEAKER_00: Alright.
• 0:45
  SPEAKER_00: Now, have you ever seen a patient with atrial fibrillation and immediately thought they're either on already or should be on anticoagulation?
• 0:54
  SPEAKER_00: I know I've made that assumption, but that assumption can actually lead to over-treatment and unnecessary bleeding risk in certain patients.
• 1:04
  SPEAKER_00: Okay.
• 1:05
  SPEAKER_00: Now, with that, let's jump into the actual question.
• 1:09
  SPEAKER_00: Okay.
• 1:09
  SPEAKER_00: So we've got a 40-year-old female patient diagnosed with atrial fibrillation.
• 1:17
  SPEAKER_00: A rate control strategy is determined to be the best intervention.
• 1:22
  SPEAKER_00: The patient has a Chad's VAS score of one.
• 1:27
  SPEAKER_00: In addition to items evaluated by the Chad VAS, there is no evidence of structural or vascular disease.
• 1:36
  SPEAKER_00: What is the recommended anticoagulation strategy in this patient?
• 1:41
  SPEAKER_00: Answer A.
• 1:42
  SPEAKER_00: No anticoagulation, the risk outweigh the benefit.
• 1:47
  SPEAKER_00: B dose adjusted warfarin with a goal INR of 2.5 to 3.5.
• 1:54
  SPEAKER_00: Dibigotran 110 milligrams by mouth twice daily.
• 1:59
  SPEAKER_00: Rivoroxaban 20 milligrams by mouth twice daily.
• 2:04
  SPEAKER_00: Okay, now this question is testing a clinical decision-making scenario related to stroke prevention in AFib.
• 2:16
  SPEAKER_00: Now, specifically, it's assessing your understanding of how the CHAD VASC score is used to stratify stroke risk and determine whether that anticoagulation therapy should be initiated.
• 2:30
  SPEAKER_00: And from an educational standpoint, guys, this question sits at the application level of Bloom's taxonomy, where you are expected to apply a clinical scoring tool to a clinical scenario and determining the correct management decision based on that calculated risk.
• 2:51
  SPEAKER_00: Okay.
• 2:52
  SPEAKER_00: Now given that let's look at a the actual score.
• 2:58
  SPEAKER_00: Okay, so this is a Chad VAS score.
• 3:00
  SPEAKER_00: I put it together for you based on the original score.
• 3:03
  SPEAKER_00: And the Chad's VAS stands for something, right?
• 3:07
  SPEAKER_00: C stands for heart failure.
• 3:11
  SPEAKER_00: And you get one point if you have that.
• 3:13
  SPEAKER_00: And there's some defined criteria there for those of you that want to dive back into that, right?
• 3:20
  SPEAKER_00: H is hypertension with a definition.
• 3:24
  SPEAKER_00: Or patients already on treatment.
• 3:26
  SPEAKER_00: People forget that one, right?
• 3:28
  SPEAKER_00: Age equal to or greater than 75, one point.
• 3:33
  SPEAKER_00: Diabetes, one point.
• 3:34
  SPEAKER_00: Stroke, TIA history, uh two points.
• 3:38
  SPEAKER_00: Okay.
• 3:39
  SPEAKER_00: I'm sorry, age over 60, 75 is two points, and then stroke is two points.
• 3:43
  SPEAKER_00: Those are the ones that throw people off a little bit, and it just did me.
• 3:45
  SPEAKER_00: Vascular disease, right?
• 3:48
  SPEAKER_00: PBD, CAD, uh PCI with vascular procedures, those are one point.
• 3:54
  SPEAKER_00: And then when you your age falls to 65 and 74, that bubble, you go from two points, mean over 75, equal to, or greater than 75, to one point.
• 4:05
  SPEAKER_00: And then female gender being listed as one for the total score of nine.
• 4:10
  SPEAKER_00: Well, once you have that, then you align the patient on their total score, and these are thresholds.
• 4:17
  SPEAKER_00: And these are the thresholds that are actually very important for you to know.
• 4:22
  SPEAKER_00: And you see here over down here, there's a male and a female side, and then the over on the other side is the actual recommendation.
• 4:31
  SPEAKER_00: And obviously, the lower the number, the less risk of concern, and the lower the chance of needing anticoagulation.
• 4:38
  SPEAKER_00: Um, but there's also the one about when you should consider it and then when it you should start it.
• 4:43
  SPEAKER_00: This is all about weighing the risk and benefit, and there's obviously a tipping point.
• 4:48
  SPEAKER_00: Okay, down at the bottom includes other factors that increase the risk of stroke for consideration.
• 4:55
  SPEAKER_00: Now, one of the potential modifiers in this case is that the patient reported to be female, and female sex contributes that one point, which is why the Chad Bath score is one.
• 5:08
  SPEAKER_00: Okay, now, however, female gender alone does not necessarily mandate anticoagulation, does it?
• 5:16
  SPEAKER_00: We just saw that.
• 5:17
  SPEAKER_00: The clinical significance of female sex becomes more important when combined with other stroke risk factors.
• 5:23
  SPEAKER_00: In addition, the question specifically tells you guys listen, there is no other evidence of structural or vascular disease, which removes several potential additional risk factors from being considered.
• 5:38
  SPEAKER_00: Don't make up things that are not there.
• 5:41
  SPEAKER_00: Okay?
• 5:42
  SPEAKER_00: Now, board questions often include distractor wording related to medication dosing.
• 5:49
  SPEAKER_00: And in this question, right, several answer choices include anticoagulants, but with incorrect dosing strategies.
• 5:59
  SPEAKER_00: Now, these are designed to test whether you recognize both the clinical indication for the for anticoagulation and the appropriate dosing regimens used for atrial fibrillation.
• 6:11
  SPEAKER_00: Now, however, you can and should technically be able to answer this question, guys, regardless of knowing the actual dosing.
• 6:21
  SPEAKER_00: Knowing the basics of when anticoagulation dosing can help further solidify your determination of the correct answer, and I'm going to walk you through that.
• 6:30
  SPEAKER_00: So the correct answer here is A, no anticoagulation.
• 6:36
  SPEAKER_00: The risk of that outweighs the benefit.
• 6:40
  SPEAKER_00: Okay?
• 6:41
  SPEAKER_00: Now, the key issue here is that the patient's ChadVass score.
• 6:47
  SPEAKER_00: The scoring system estimates the stroke risk in patients with AFib.
• 6:50
  SPEAKER_00: And again, we're going back to the table.
• 6:53
  SPEAKER_00: This is where we determine that from an application standpoint.
• 6:58
  SPEAKER_00: But again, even if you didn't memorize this table, right, and it's all of its detail, if you understand this area of the thresholds, okay, then that guides you to the decision.
• 7:13
  SPEAKER_00: And that's the core concept that is being tested here.
• 7:17
  SPEAKER_00: So think about it in this way.
• 7:19
  SPEAKER_00: You know, the goal for anticoagulation is to prevent a stroke.
• 7:23
  SPEAKER_00: But if the baseline risk is already extremely low, exposing that patient to bleeding risk may cause more harm than benefit.
• 7:31
  SPEAKER_00: And that is why the recommended strategy for this patient is no anticoagulation.
• 7:37
  SPEAKER_00: Okay?
• 7:38
  SPEAKER_00: Now let's go back to the question.
• 7:40
  SPEAKER_00: Let's review the correct the other answers and why they are incorrect.
• 7:45
  SPEAKER_00: Doing this actually can help you to learn other important concepts that could also be tested in the future or on other questions.
• 7:54
  SPEAKER_00: So option B, dose-adjusted warfarin with a goal INR of 2.5 to 3.5.
• 8:00
  SPEAKER_00: Well, first, anticoagulation is not necessary in this patient.
• 8:04
  SPEAKER_00: Yes, we agree.
• 8:06
  SPEAKER_00: Second, even when warfarin is used for atrial fibrillation and stroke prevention, the target INR is typically 2 to 3, not 2.5 to 3.5.
• 8:17
  SPEAKER_00: So that's a again a distractor making it wrong.
• 8:21
  SPEAKER_00: You might use that in somebody with a mechanical heart valve, right?
• 8:24
  SPEAKER_00: Or patients with lupus that are still clotting.
• 8:27
  SPEAKER_00: Option C suggests debigotran, 110 milligrams twice by mouth twice a day.
• 8:33
  SPEAKER_00: Well, that dose that is not the standard dosing regimen for this, okay, in patients with atrial fibrillation for stroke prevention.
• 8:41
  SPEAKER_00: For most patients with atrial fibrillation, debigotran is dosed at 150 milligrams twice daily.
• 8:47
  SPEAKER_00: Now, the 110 milligram BID dosing that you see here is considered kind of more off-label use in patients who do have a higher bleeding risk.
• 8:58
  SPEAKER_00: Lastly, option D, riveroxaban, okay, 20 milligrams twice a day by mouth.
• 9:04
  SPEAKER_00: The appropriate dose of riveroxaban for stroke prevention, okay, in patients with the original indication, non-valvular atrial fibrillation, is 20 milligrams daily in the evening with meal.
• 9:18
  SPEAKER_00: Okay, so therefore, all of these answers represent incorrect therapy and more importantly, therapy that is not indicated in a low-risk patient.
• 9:31
  SPEAKER_00: Now, this core teaching point is that the Chad Bath score is used to determine whether anticoagulation is appropriate in patients with atrial fibrillation.
• 9:39
  SPEAKER_00: Okay, patients with a score of zero in male, one in females have a very low annual risk of stroke.
• 9:48
  SPEAKER_00: That means if you break that risk down per day, it's very, very low.
• 9:53
  SPEAKER_00: Okay, and those patients should not receive anticoagulation.
• 9:58
  SPEAKER_00: Recognizing this threshold is critical because it prevents unnecessary exposure to bleeding risk.
• 10:05
  SPEAKER_00: Okay, for board exams, always remember that that ChadVass score threshold, zero in males, one in female means no anticoagulation.
• 10:13
  SPEAKER_00: Okay, a score of one in males or two in females, okay.
• 10:19
  SPEAKER_00: That threshold, now it's considered you consider the use of anticoagulation depending on individual other risk factors, right?
• 10:27
  SPEAKER_00: That I listed at the bottom of that table.
• 10:29
  SPEAKER_00: And a score of two or more in males or three or more in females typically indicates that anticoagulation should be started.
• 10:40
  SPEAKER_00: Now, if you remember those, if you memorize those thresholds, many board questions become much easier to answer.
• 10:46
  SPEAKER_00: And this is why a tool, right, like this score, can be so important not only on your exams but also clinical practice.
• 10:55
  SPEAKER_00: They allow clinicians to balance that risk and benefit of therapy using evidence-based risk stratification.
• 11:03
  SPEAKER_00: All right, guys.
• 11:03
  SPEAKER_00: Well, I hope you found that breakdown helpful.
• 11:06
  SPEAKER_00: And remember that mastering board exams requires more than just memorizing facts, it requires practicing clinical reasoning through questions just like this one.
• 11:18
  SPEAKER_00: And that's why I created high yield med reviews, where we focus on applying knowledge to board exam style questions across medicine, pharmacy, and other advanced practice exams.
• 11:32
  SPEAKER_00: You can learn more about that and access discounts to that program if you so need it through free membership at thisiswhy.
• 11:41
  SPEAKER_00: Thank you guys for watching.
• 11:42
  SPEAKER_00: This is why with Dr.
• 11:43
  SPEAKER_00: Busdy.
• 11:44
  SPEAKER_00: I'll see you next time on the next episode.
• 11:47
  SPEAKER_00: Take care, everybody.