The role of finerenone in heart failure

Heart failure (HF) with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) represents approximately half of all HF cases, yet therapeutic options are limited. Mineralocorticoid receptor (MR) overactivation by aldosterone has long been recognized as a key driver of vascular inflammation, cardiac fibrosis, and cardiac hypertrophy, pathophysiological processes integral to the development and progression of HFmrEF/HFpEF. The non-steroidal MRA finerenone has been developed with a distinct pharmacological profile: potent and selective MR blockade with a reduced risk of off-target hormone-related side effects. Large, multicenter randomized placebo-controlled trials in chronic kidney disease and type 2 diabetes patients (FIDELIO-DKD, FIGARO-DKD) first highlighted finerenone's cardiorenal benefits, including a reduction in death from cardiovascular causes and hospitalization for HF. More recently, the FINEARTS-HF trial extended this evidence to patients with HFmrEF/HFpEF, demonstrating a significant reduction in the risk of worsening HF events and death from cardiovascular causes. Ongoing studies, such as REDEFINE-HF, CONFIRMATION-HF, and FINALITY-HF, will examine the potential role of finerenone in HF across a broad spectrum of ejection fractions and different clinical settings. This review synthesizes the evolving evidence supporting the role of finerenone as a new option in the management of HF.