Anticoagulant Therapy in Atrial Fibrillation for Stroke Prevention: Assessment of Agreement Between Clinicians’ Decision and CHA2DS2-VASc and HAS-BLED Scores

  • Marzieh Balaghi-Inalou
  • Saeed Alipour Parsa
  • Latif Gachkar
  • Sasan Andalib
Original Article



To prevent stroke, anticoagulants should be administered after calculation of CHA2DS2-VASc and HAS-BLED scores in patients with Atrial Fibrillation (AF); nonetheless, these scores are sometimes neglected in clinical settings.


The present study was designed to assess agreement of anticoagulant therapy according to clinicians and CHA2DS2-VASc and HAS-BLED scores in Iranian AF patients in Moddares Hospital.


AF patients were diagnosed according to clinical history, clinical examination, and electrocardiogram. Data including the anticoagulant prescription according to clinicians were recorded. CHA2DS2-VASc and HAS-BLED scores were then calculated for each patient. Agreement of anticoagulant therapy according to clinicians and CHA2DS2-VASc and HAS-BLED scores was analyzed using Cohen’s kappa coefficient.


97.5% of the patients (n = 117) were appropriately (according CHA2DS2-VASc and HAS-BLED scores) treated with anticoagulants by clinicians, notwithstanding a 2.5% of patients with inappropriate anticoagulant therapy (n = 3). The Cohen’s kappa coefficient was 0.81 (P = 0.0).


The findings of the present study suggest an almost perfect agreement between anticoagulant therapy according to clinicians and that according to CHA2DS2-VASc and HAS-BLED scores in the studied population.


Atrial fibrillation Clinician decision CHA2DS2-VASc HAS-BLED Agreement assessment 



We thank Shahid Beheshti University of Medical Sciences for its support.

Compliance with Ethical Standards

Conflict of interest

The authors declare that there is no conflict of interest regarding the present study.

Ethical approval

The present study was approved by local ethics committee.

Informed consent

Written informed consent was obtained from each patient.


  1. 1.
    Murphy NF, Simpson CR, Jhund PS, Stewart S, Kirkpatrick M, Chalmers J, et al. A national survey of the prevalence, incidence, primary care burden and treatment of atrial fibrillation in Scotland. Heart (British Cardiac Society). 2007;93(5):606–12. doi: 10.1136/hrt.2006.107573.CrossRefGoogle Scholar
  2. 2.
    Miyasaka Y, Barnes ME, Gersh BJ, Cha SS, Bailey KR, Abhayaratna WP, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006;114(2):119–25. doi: 10.1161/circulationaha.105.595140.CrossRefPubMedGoogle Scholar
  3. 3.
    Watanabe H, Tanabe N, Watanabe T, Darbar D, Roden DM, Sasaki S, et al. Metabolic syndrome and risk of development of atrial fibrillation: the Niigata preventive medicine study. Circulation. 2008;117(10):1255–60. doi: 10.1161/circulationaha.107.744466.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Talebi M, Ghertasi M, Taheraghdam A, Andalib S, Sharifipour E. A comparison of risk factors and severity of ischemic stroke in female and male genders in North-West Iran: a cross-sectional study. Iran J Neurol. 2014;13(4):215–9.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Shaafi S, Sharifipour E, Rahmanifar R, Hejazi S, Andalib S, Nikanfar M, et al. Interleukin-6, a reliable prognostic factor for ischemic stroke. Iran J Neurol. 2014;13(2):70–6.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Andalib S, Divani AA, Michel TM, Hoilund-Carlsen PF, Vafaee MS, Gjedde A. Pandora’s box: mitochondrial defects in ischaemic heart disease and stroke. Expert Rev Mol Med. 2017;19:e5. doi: 10.1017/erm.2017.5.CrossRefPubMedGoogle Scholar
  7. 7.
    Wolf PA, Dawber TR, Thomas HE, Kannel WB. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke the Fiamingham study. Neurology. 1978;28(10):973.CrossRefPubMedGoogle Scholar
  8. 8.
    Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001. doi: 10.1001/jama.285.22.2864.PubMedGoogle Scholar
  9. 9.
    Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham study. Arch Intern Med. 1987;147(9):1561–4.CrossRefPubMedGoogle Scholar
  10. 10.
    Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke. 1991. doi: 10.1161/01.str.22.8.983.Google Scholar
  11. 11.
    Lane DA, Lip GY. Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation. 2012;126(7):860–5. doi: 10.1161/circulationaha.111.060061.CrossRefPubMedGoogle Scholar
  12. 12.
    Friberg L, Rosenqvist M, Lip GY. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation Cohort study. Eur Heart J. 2012;33(12):1500–10. doi: 10.1093/eurheartj/ehr488.CrossRefPubMedGoogle Scholar
  13. 13.
    Olesen JB, Torp-Pedersen C, Hansen ML, Lip GY. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0–1: a nationwide cohort study. Thromb Haemost. 2012;107(6):1172–9. doi: 10.1160/th12-03-0175.CrossRefPubMedGoogle Scholar
  14. 14.
    Gage BF, Yan Y, Milligan PE, Waterman AD, Culverhouse R, Rich MW, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006;151(3):713–9. doi: 10.1016/j.ahj.2005.04.017.CrossRefPubMedGoogle Scholar
  15. 15.
    Srivastava A, Hudson M, Hamoud I, Cavalcante J, Pai C, Kaatz S. Examining warfarin underutilization rates in patients with atrial fibrillation: detailed chart review essential to capture contraindications to warfarin therapy. Thromb J. 2008;6(1):6. doi: 10.1186/1477-9560-6-6.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Boulanger L, Kim J, Friedman M, Hauch O, Foster T, Menzin J. Patterns of use of antithrombotic therapy and quality of anticoagulation among patients with non-valvular atrial fibrillation in clinical practice. Int J Clin Pract. 2006;60(3):258–64. doi: 10.1111/j.1368-5031.2006.00790.x.CrossRefPubMedGoogle Scholar
  17. 17.
    Birman-Deych E, Radford MJ, Nilasena DS, Gage BF. Use and effectiveness of warfarin in Medicare beneficiaries with atrial fibrillation. Stroke. 2006;37(4):1070–4. doi: 10.1161/01.STR.0000208294.46968.a4.CrossRefPubMedGoogle Scholar
  18. 18.
    Cyr L, Francis K. Measures of clinical agreement for nominal and categorical data: the kappa coefficient. Comput Biol Med. 1992;22(4):239–46. doi: 10.1016/0010-4825(92)90063-S.CrossRefPubMedGoogle Scholar
  19. 19.
    Meiltz A, Zimmermann M, Urban P, Bloch A. Atrial fibrillation management by practice cardiologists: a prospective survey on the adherence to guidelines in the real world. Europace. 2008;10(6):674–80. doi: 10.1093/europace/eun086.CrossRefPubMedGoogle Scholar
  20. 20.
    Gandolfo C, Balestrino M, Burrone A, Del Sette M, Finocchi C. Stroke due to atrial fibrillation and the attitude to prescribing anticoagulant prevention in Italy. A prospective study of a consecutive stroke population admitted to a comprehensive stroke unit. J Neurol. 2008;255(6):796–802. doi: 10.1007/s00415-008-0615-2.CrossRefPubMedGoogle Scholar
  21. 21.
    Inoue H, Nozawa T, Hirai T, Iwasa A, Okumura K, Lee J-D, et al. Accumulation of risk factors increases risk of thromboembolic events in patients with nonvalvular atrial fibrillation. Circ J. 2006;70(6):651–6. doi: 10.1253/circj.70.651.CrossRefPubMedGoogle Scholar
  22. 22.
    Partington SL, Abid S, Teo K, Oczkowski W, O’Donnell MJ. Pre-admission warfarin use in patients with acute ischemic stroke and atrial fibrillation: the appropriate use and barriers to oral anticoagulant therapy. Thromb Res. 2007;120(5):663–9. doi: 10.1016/j.thromres.2006.12.019.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Marzieh Balaghi-Inalou
    • 1
  • Saeed Alipour Parsa
    • 1
  • Latif Gachkar
    • 1
  • Sasan Andalib
    • 2
  1. 1.Cardiovascular Research Center, Department of Cardiology, Modarres Hospital, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
  2. 2.Neuroscience Research Center, Department of Neurosurgery, Poursina Hospital, School of MedicineGuilan University of Medical SciencesRashtIran

Personalised recommendations