A Review on Finerenone and Heart Failure with Preserved Ejection Fraction (HFpEF)

Heart failure with preserved ejection fraction (HFpEF) accounts for about half of all heart failure cases and is difficult to treat because it has many causes and limited treatment options. Finerenone is a newer nonsteroidal mineralocorticoid receptor antagonist (MRA) that is more selective, distributes evenly between the heart and kidneys, and leads to fewer hormone-related side effects than older steroidal MRAs.

This review examines results from key clinical trials, such as FIDELIO-DKD, FIGARO-DKD, and FINEARTS-HF, as well as recent studies that have followed patients and explored how finerenone works in HFpEF and heart failure with mildly reduced ejection fraction (HFmrEF). Studies published between 2020 and 2025 were found using PubMed, Embase, Scopus, and the Cochrane Library.

Clinical trials found that finerenone reduced the risk of cardiovascular events, including heart failure hospitalizations and cardiovascular death, regardless of ejection fraction. Biomarker analysis showed lower NT-pro BNP levels, improved diastolic function, and less cardiac remodeling. Finerenone also had strong anti-inflammatory and antifibrotic effects, maintained renal safety, and caused less hyperkalemia than steroidal mineralocorticoid receptor antagonists (MRAs). These benefits appeared in all groups, no matter their age, sex, kidney function, or use of sodium-glucose cotransporter 2 (SGLT2) inhibitors.

Finerenone provides cardiorenal protection by targeting key inflammatory and fibrotic pathways in HFpEF. Its favorable safety profile and additive effects with SGLT2 inhibitors support its integration into evolving guideline-directed therapy.

Finerenone is a significant step forward in treating HFpEF, as it provides both heart and kidney protection. Current studies will help identify which patients benefit most and how it affects long-term results in more people with HFpEF.