Abstract Background: The 2024 ESC atrial fibrillation (AF) guidelines introduced the CHA₂DS₂-VA score, eliminating female sex as an independent risk criterion for stroke risk stratification. This revision aimed to improve clarity and avoid sex-based overtreatment. However, its real-world impact on women with ischemic stroke remains unclear. 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 Conclusion: The removal of female sex from the CHA₂DS₂-VA score does not eliminate sex-specific disparities in stroke risk. A clinically meaningful subgroup of women now falls below treatment thresholds, raising concern for under-treatment. These findings call for nuanced anticoagulation strategies that go beyond score-based decisions and better reflect real-world risk in female stroke patients with AF.
Boettger et al. (Fri,) studied this question.
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