Chronic kidney disease, atrial fibrillation, and stroke: risk scores in the era of SGLT2i, non-steroidal MRA, and GLP-1 RA, and presence of high competing mortality

Abstract

Atrial fibrillation (AF) and chronic kidney disease (CKD) frequently coexist, share risk factors and pathophysiology, and confer a high burden of stroke, bleeding, heart failure, and premature death. Risk scores such as CHA₂DS₂-VASc, which estimates thromboembolic risk, and HAS-BLED, which estimates bleeding risk, were derived in populations including relatively few patients with advanced CKD. Consequently, they may not adequately account for CKD-specific modifiers of thromboembolic and hemorrhagic risk. Although these scores do not formally incorporate competing non-stroke mortality, higher CHA₂DS₂-VASc scores may indirectly identify patients with a greater competing risk of death. Meanwhile, widespread use of renin–angiotensin–aldosterone system blockade, mineralocorticoid receptor antagonists, sodium–glucose cotransporter 2 inhibitors, and glucagon-like peptide‑1 receptor agonists has reshaped cardiorenal prognosis, further challenging historical calibrations of stroke and bleeding scores. In this perspective, we critically appraise conventional risk scores in AF with CKD, highlight their limitations in the context of modern preventive therapies and competing mortality, and outline priorities for more dynamic, kidney‑focused risk stratification.