Written by Babatunde Carew
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Finerenone significantly reduced worsening heart failure (HF) events and composite cardiovascular outcomes in HF with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) but did not improve cardiovascular mortality.
Synopsis
This randomized, double-blind, international trial assessed the efficacy of finerenone in HFmrEF/HFpEF patients. Over 6,001 patients were randomized to finerenone or placebo, with a median follow-up of 32 months. The primary composite outcome — worsening heart failure events and cardiovascular death — occurred less frequently in the finerenone group (rate ratio 0.84, 95%CI 0.74-0.95, p=0.007). Secondary outcomes included improved symptom scores, but no significant change in NYHA functional class. Limitations included low representation of Black patients and subgroup power. Notably, finerenone reduced cardiovascular outcomes but increased hyperkalemia risk. (AI-generated, physician edited)
Finerenone, eplerenone…I’m still using spironolactone
There is robust evidence supporting guideline-directed medical therapy in HFrEF, but data for HFpEF remain limited. TOPCAT showed spironolactone offered no significant effect on composite cardiac outcomes in HFpEF, but reduced heart failure hospitalizations. SGLT2 inhibitors, like empagliflozin, have shown benefit in reducing cardiovascular death and hospitalizations in HFpEF (EMPEROR). Now, a new challenger enters the ring… but not the loop of Henle.
Finerenone, a non-steroidal mineralocorticoid receptor antagonist, has been shown to reduce chronic kidney disease progression and cardiovascular events in type 2 diabetes (FIDELIO-DKD; FIGARO-DKD), but its clinical utility in HFpEF remains unknown. In the FINEARTS-HF trial, finerenone significantly decreased worsening HF events (18%) and the primary composite outcome in HFmrEF and HFpEF, but there was no statistically significant change in cardiovascular deaths.
Overall, this study is not practice-changing for me. The FINEARTS-HF trial mirrors TOPCAT. I suspect that a subgroup analysis of the HFpEF population might reveal less benefit compared to the combined HFmrEF and HFpEF group. Further, since HFmrEF is often treated like HFrEF in clinical practice, finerenone’s added value in this population depends on future studies comparing it to spironolactone. At around $700 on GoodRx, it’s hard to justify prescribing without evidence of clear and marked superiority. Notably, the trial was sponsored by Bayer, finerenone’s manufacturer.
Source
Finerenone in Heart Failure with Mildly Reduced or Preserved Ejection Fraction. N Engl J Med. 2024 Oct 24;391(16):1475-1485. doi: 10.1056/NEJMoa2407107. Epub 2024 Sep 1. PMID: 39225278
