Key result
Finerenone linked to ~28% lower risk of death or HF exacerbation vs. spironolactone.
Why the study?
Head-to-head data comparing finerenone versus spironolactone in heart failure with mildly reduced or preserved ejection fraction are limited.
Does finerenone reduce all-cause mortality or heart failure exacerbation compared to spironolactone in adults with heart failure with mildly reduced or preserved ejection fraction?
Cohort (n=2,834)
Yes
Does finerenone reduce all-cause mortality or heart failure exacerbation compared to spironolactone in adults with heart failure with mildly reduced or preserved ejection fraction?
Hazard Ratio: 0.72 (95% CI 0.64–0.82)
Absolute Event Rate: 32.3% vs 41.7%
p-value: p=< 0.001
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“If we're going to follow the evidence and what the literature would tell us, finerenone would be a primary strategy in those patients with an EF ≥40% if finerenone is not available, or if there are other barriers that might restrict the use of finerenone. Spironolactone is maybe an option B for a patient on the edges, but for most of our patients, we believe the data – finerenone seems to be the most effective MRA for those patients.”
In a real-world cohort of patients with HFmrEF/HFpEF, finerenone was associated with lower risks of mortality, heart failure exacerbation, and hyperkalemia compared to spironolactone over 12 months.
AIMS: Finerenone has shown benefit in chronic kidney disease, type 2 diabetes, and heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF), but head-to-head data against spironolactone are limited. We compared 12-month effectiveness and safety after finerenone versus spironolactone initiation in heart failure with left ventricular ejection fraction ≥40%. METHODS AND RESULTS: We conducted a retrospective active-comparator, new-user cohort study using the TriNetX Network from 9 July 2021 to 31 March 2025. Adults of both sexes with HFmrEF/HFpEF initiating finerenone or spironolactone were matched 1:1 by propensity score. The primary outcome was all-cause mortality or heart failure exacerbation. Secondary outcomes included all-cause mortality, heart failure exacerbation, all-cause hospitalisation, and acute myocardial infarction; safety outcomes were hyperkalaemia and acute kidney injury. After matching, 1417 patients were included in each group. Finerenone initiation was associated with lower risk of the primary outcome (32.3% vs. 41.7%; adjusted hazard ratio [aHR] 0.72, 95% confidence interval [CI] 0.64-0.82; P < 0.001). Lower risks were also observed for all-cause mortality (aHR 0.67, 95% CI 0.51-0.87), heart failure exacerbation (aHR 0.73, 95% CI 0.64-0.83), and all-cause hospitalisation (aHR 0.83, 95% CI 0.76-0.91), but not acute myocardial infarction. Hyperkalaemia was less frequent with finerenone (17.9% vs. 22.8%; risk ratio 0.79, 95% CI 0.68-0.91); acute kidney injury showed only a borderline difference. CONCLUSIONS: Finerenone initiation was associated with lower 12-month clinical event and hyperkalaemia risks than spironolactone initiation. These observational associations should be considered hypothesis-generating and require confirmation in randomised head-to-head trials.
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Ha et al. (2026) conducted a cohort in Heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) (n=2,834). Finerenone vs. Spironolactone was evaluated on All-cause mortality or heart failure exacerbation (aHR 0.72, 95% CI 0.64-0.82, p=< 0.001). Finerenone initiation was associated with a lower risk of all-cause mortality or heart failure exacerbation compared to spironolactone (32.3% vs. 41.7%; aHR 0.72; 95% CI 0.64-0.82; P<0.001).
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