Finerenone in Heart Failure with Preserved Ejection Fraction: Expanding the Role of Non-steroidal Mineralocorticoid Receptor Antagonists

PURPOSE OF REVIEW: To evaluate the role of finerenone, a nonsteroidal mineralocorticoid receptor antagonist (MRA), in heart failure with preserved or mildly reduced ejection fraction (HFpEF/HFmrEF). RECENT FINDINGS: Finerenone has demonstrated cardiovascular and renal benefits in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D), including reductions in hospitalizations for heart failure (HF). The FINEARTS-HF trial showed a reduced rate of worsening HF events in patients with left ventricular ejection fraction (LVEF) ≥40%, independent of CKD or T2D status. Preclinical studies suggest that antifibrotic and anti-inflammatory effects are distinct from those of steroidal MRAs. Ongoing trials are evaluating finerenone across various HF phenotypes and in combination with concomitant sodium-glucose cotransporter-2 inhibitors (SGLT2i). Finerenone is a promising therapy for HFpEF/HFmrEF, particularly in patients with the cardiovascular-kidney-metabolic syndrome (CKM). Hyperkalemia may potentially occur, especially in patients with reduced renal function, and requires monitoring and dose adjustments. Further studies are needed to identify which other HF and non-HF cohorts are most likely to benefit.