Clinical question: Does finerenone improve outcomes in patients with heart failure (HF) with mildly reduced or preserved ejection fraction?
Background: Steroidal mineralocorticoid receptor antagonists have proven benefits in HF with reduced ejection fraction, but their role in preserved ejection fraction remains unclear. Finerenone, a novel nonsteroidal mineralocorticoid receptor antagonist, needs evaluation in this population.
Study design: International, double-blind, randomized controlled trial
Setting: Multiple international centers
Synopsis: This study included 6,001 patients with HF and left ventricular ejection fraction at least 40%. Patients were randomized to receive either finerenone (20 to 40 mg daily) or placebo in addition to standard therapy. Over a median follow-up of 32 months, the finerenone group experienced significantly fewer primary outcome events (1,083 versus 1,283 events; rate ratio 0.84; 95% CI, 0.74 to 0.95; P=0.007). The primary outcome was a composite of total worsening HF events and death from cardiovascular causes. The total number of worsening HF events was also lower in the finerenone group (842 versus 1,024; rate ratio, 0.82). Cardiovascular death rates were similar between groups (8.1% versus 8.7%). Safety analysis showed increased hyperkalemia but reduced hypokalemia with finerenone. Limitations include low numbers of enrolled Black patients in the cohort and underpowering of all prespecified subgroups.
Bottom line: Finerenone significantly reduces worsening HF events in patients with mildly reduced or preserved ejection fraction, though without affecting cardiovascular mortality.
Citation: Solomon SD, et al. Finerenone in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med. 2024;391(16):1475-85. doi: 10.1056/NEJMoa2407107.
Dr. Glikes is an academic hospitalist in the section of hospital medicine at UPMC Presbyterian Hospital, and a clinical assistant professor of medicine at the University of Pittsburgh School of Medicine, both in Pittsburgh.