Does CHA₂DS₂-VASc score select patients who will benefit most from anticoagulation?

We have read the article by Barrios et al on the use of anticoagulation therapy in patients with atrial fibrillation in an unselected population in primary care. We consider it a very important study because it highlights the great room for improvement in daily practice and that, regardless of the embolic risk scale chosen, about 45% of patients without an indication receive anticoagulation therapy (CHADS2 and CHA2DS2-VASc score = 0), whereas more than 40% of patients with a clear indication do not. However, the reason for this letter concerns our disagreement with the authors’ statement that the CHA2DS2-VASc scale ‘‘...enables better identification of those patients with AF who will most benefit from anticoagulation therapy than the CHADS2 score’’. Although it is true that when minor criteria (female sex, age 65-74 years, or vascular disease) are taken into account the predictive power of embolic events increases, we believe that basing the indication for anticoagulation therapy on these alone, in the absence of any major criterion, leads to many patients with a very low risk of embolism receiving anticoagulation therapy regardless of the net clinical benefit we wish to obtain (reducing thromboembolic risk while reducing severe bleeding risk). This idea is supported by information from a Danish registry on atrial fibrillation, which investigated reductions in the risk of stroke and intracranial bleeding. There was an evident lack of net clinical benefit in patients with a CHA2DS2-VASc score = 1 and a very slight net clinical benefit in those with a CHADS2 score = 1. This difference between the 2 scales can only be explained by the zero net clinical benefit of anticoagulation