Finerenone Versus Spironolactone for Heart Failure with Preserved Ejection Fraction

Area of Science:

• Cardiology
• Pharmacology

Background:

• Mineralocorticoid receptor antagonists (MRAs) are crucial for managing heart failure with preserved ejection fraction (HFpEF).
• Comparative effectiveness data between steroidal (e.g., spironolactone) and nonsteroidal (e.g., finerenone) MRAs in HFpEF is limited.
• Understanding differential outcomes is vital for optimizing HFpEF treatment strategies.

Purpose of the Study:

• To directly compare the cardiovascular and safety outcomes of finerenone versus spironolactone in patients with HFpEF.
• To evaluate the comparative effectiveness of steroidal and nonsteroidal MRAs in a real-world HFpEF population.

Main Methods:

• Retrospective cohort study utilizing a global federated health research network.
• Inclusion of adult patients with new-onset HFpEF between January 2021 and August 2025.
• Propensity score matching (1:1) to balance baseline characteristics, followed by Cox proportional hazards modeling for outcome assessment.

Main Results:

• Acute heart failure events were similar between finerenone and spironolactone groups (HR 1.26).
• All-cause mortality was significantly lower in the finerenone cohort compared to spironolactone (HR 0.48).
• Major adverse cardiovascular events, acute kidney injury, and hyperkalemia rates were comparable between the two MRA groups.

Conclusions:

• Finerenone demonstrates comparable effectiveness and safety to spironolactone in HFpEF patients.
• The observed lower all-cause mortality with finerenone warrants further investigation.
• These findings are hypothesis-generating, supporting the need for prospective trials to confirm efficacy and safety profiles.