Risk stratification for stroke in atrial fibrillation: a critique

Despite the demonstrable success of oral anticoagulants in reducing the rate of stroke in patients with atrial fibrillation, they continue to be seriously underutilized. Indications for their use as stated in the guidelines incorporate a number of risk score algorithms, the most widely used being the CHA2DS2-VASc score. Nonetheless there are several limitations to the various scores currently in clinical use and a critique of these is the focus of this review. In this review we discuss the pathophysiology of atrial fibrillation and its role in thromboembolic stroke risk. We amalgamate this with the basis of major professional society anticoagulation recommendations with regards to the strengths and limitations of current risk stratification strategies and discuss gaps in our current evidence base and next steps to address those gaps.