心不全（HFpEF）におけるステロイド系および非ステロイド系ミネラルコルチコイド受容体拮抗薬：傾向スコアマッチングによる多施設ネットワーク全国コホート研究

Heart failure continues to portend significant morbidity and mortality within the United States. Data regarding the efficacy of mineralocorticoid receptor antagonists (MRAs) in heart failure with preserved ejection fraction (HFpEF) remains unclear. Finerenone, a non-steroidal MRA, has demonstrated reduction in hospitalizations in this population. However, the comparative efficacy of different MRA classes in these patients remains elusive.

We conducted a retrospective observational cohort study using the TriNetX research network. We applied 1:1 propensity score matching to compare patients with HFpEF initiated on finerenone versus spironolactone. We examined 1-year risks of heart failure exacerbation, acute kidney injury, electrolyte derangements, and cardiovascular outcomes.

We identified 254,417 patients with HFpEF and MRA use. After propensity score matching, each cohort contained 491 patients. Analysis revealed that finerenone use was associated with a significantly lower risk of heart failure exacerbation (HR = 0.63 [95% CI: 0.54, 0.74], p < 0.001), all-cause mortality (HR = 0.38 [95% CI: 0.23, 0.64], p < 0.001), and hypokalemia (HR = 0.58 [95% CI: 0.40, 0.85], p = 0.001). The aforementioned results, along with a reduction in AKI risk, were statistically significant after stratified subgroup analysis by DM and CKD.

In this large real-world HFpEF cohort, finerenone use was associated with lower risks of heart failure exacerbation and all-cause mortality compared with spironolactone. These observational findings are hypothesis-generating and warrant confirmation in randomized trials.