What does this research mean for the field?

Finerenone significantly reduces hospitalization for heart failure compared to placebo in patients with HFpEF/HFmrEF, while no mineralocorticoid receptor antagonist significantly reduces cardiovascular mortality. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

March 16, 2026

Finerenone, Eplerenone, and Spironolactone in HFpEF: A Bayesian Network Meta-Analysis of Efficacy and Safety

Resultado clave

Finerenone reduced hospitalization for heart failure by 16% versus placebo (RR 0.84; 95% CrI 0.75-0.93), while other MRAs showed nonsignificant effects.

Puntos clave

The aim is to compare the efficacy and safety of finerenone, eplerenone, and spironolactone in treating HFpEF/HFmrEF.
Analyzed eight randomized controlled trials
Conducted a fixed-effects Bayesian network meta-analysis
Estimated risk ratios for hospitalization, cardiovascular death, and hyperkalemia
Assessed heterogenicity using I2
Finerenone significantly reduced hospitalization for heart failure (RR 0.84; 95% CrI 0.75-0.93)
Spironolactone and eplerenone showed nonsignificant effects on hospitalization
None of the MRAs significantly reduced cardiovascular mortality
All MRAs increased risk of hyperkalemia significantly

PICO estructurado

Do mineralocorticoid receptor antagonists (finerenone, eplerenone, spironolactone) reduce hospitalization for HF and cardiovascular death compared to placebo in adults with HFpEF or HFmrEF?

Población

8 RCTs pooling 10,644 adults with HFpEF or HFmrEF (LVEF ≥40%), mean age 70.2, 48% women, mean LVEF 54.9%.

Intervención

Mineralocorticoid receptor antagonists (finerenone, eplerenone, spironolactone)

Comparador

Placebo

Resultado

Hospitalization for HFhard clinical

In a network meta-analysis of patients with HFpEF/HFmrEF, finerenone was the only MRA to significantly reduce heart failure hospitalizations compared to placebo, though all MRAs increased the risk of hyperkalemia.

Resultado numérico

Tasa de eventos absoluta: 0% vs 0%

Resumen

Abstract Background and Aims The comparative effects of mineralocorticoid receptor antagonists (MRAs) in heart failure with preserved ejection fraction (HFpEF) or mildly reduced ejection fraction (HFmrEF) remain uncertain, including potential differences between steroidal MRAs and finerenone. This Bayesian network meta-analysis (NMA) aimed to compare the efficacy and safety of finerenone, eplerenone, and spironolactone versus placebo in HFpEF/HFmrEF. Methods and Results We searched Pubmed, Cochrane and Embase for studies focused on MRA treatment in HFpEF and/or HFmrEF. Eight randomized controlled trials enrolling adults with HFpEF or HFmrEF (LVEF ≥40%) were analyzed in a fixed-effects Bayesian NMA. Risk ratios (RRs) with 95% credible intervals (CrIs) were estimated for hospitalization for HF, cardiovascular death, and hyperkalemia. Heterogenicity was accessed using I2. Across a network comprising 10,644 patients, mean age 70.2; 48% women; mean LVEF 54.9%, finerenone reduced hospitalization for HF versus placebo (RR 0.84; 95% CrI 0.75-0.93), whereas spironolactone (RR 0.86; 95% CrI 0.73-1.01) and eplerenone (RR 0.86; 95% CrI 0.59-1.26) showed nonsignificant effects. None of the MRAs achieved a statistically significant reduction in cardiovascular mortality versus placebo: finerenone (RR 0.93; 95% CrI 0.78-1.10), spironolactone (RR 0.93; 95% CrI 0.76-1.14), and eplerenone (RR 1.10; 95% CrI 0.29-5.69). All MRAs increased hyperkalemia versus placebo: finerenone (RR 2.06; 95% CrI 1.77-2.41), spironolactone (RR 2.13; 95% CrI 1.81-2.53), and eplerenone (RR 2.17; 95% CrI 0.75-7.97). Conclusion In HFpEF/HFmrEF, finerenone was the only MRA to significantly reduce hospitalization for HF, while no agent significantly reduced cardiovascular mortality and hyperkalemia risk increased across therapies. Overall, finerenone may offer the most favorable efficacy-safety balance among MRAs, pending confirmation in larger dedicated trials.

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