Real-life indications of finerenone in patients with heart failure with mildly reduced or preserved ejection fraction

Background

Steroideal mineralocorticoid receptor antagonist (MRA) has shown benefit in reducing heart failure (HF) hospitalizations in patients with HF and preserved ejection fraction (HFpEF) (1). Recent evidence from the FINEARTS-HF trial showed a reduction of a composite of worsening HF and cardiovascular mortality in patients with HF and left ventricular ejection fraction (LVEF) ≥40% treated with finerenone (2). However, real-world data on patient eligibility for finerenone in contemporary HF populations are needed.

Purpose

To assess the eligibility for finerenone therapy in a real-world population of patients with HF and LVEF ≥40% followed in a tertiary outpatient HF clinic over a one-year period and treated according to contemporary pharmacotherapy.

Methods

Patients attending our HF clinic between November 2024 and November 2025 with available data on LVEF were screened for inclusion. Clinic and demographic data were retrospectively collected from hospital registries. Patients with a diagnosis of HF and LVEF ≥40% with structural heart disease were considered potentially eligible. Eligibility for finerenone was assessed according to the inclusion and exclusion criteria of the FINEARTS-HF trial (2).

Results

Among 1279 outpatients attending the HF clinic over the study period, 957 (74.8%) had LVEF ≥40%. Of these, 435 patients (45.5%) fulfilled the inclusion criteria according to FINEARTS-HF trial eligibility (Figure 1) (2). The majority of patients had a diagnosis of HFpEF (58.2%); while the 15.4% and 26.4% of eligible patients suffered respectively from HF with mildly reduced ejection fraction (HFmrEF) and HF with improved ejection fraction (HFimpEF).

The most common comorbidities were hypertension (86.9%), atrial fibrillation (66.5%), and chronic kidney disease (CKD) (55.3%). 38.8% of the eligible population suffered from type 2 diabetes and 12.8% had a prior stroke. The majority of patients were treated with betablockers (87.8%); while only 37.4% assumed sodium-glucose cotransporter inhibitors.

The main exclusion criteria limiting eligibility were NYHA class < II (46.4%), the absence of HF related symptoms requiring diuretic therapy in the prior 30 days (36.1%), and serum potassium level above 5 mmol/L (8.8%). Less frequent exclusion criteria were specific cardiac pathologies with a dedicated therapeutic strategy (4%), CKD with a glomerular filtration relate below 25 ml/min/1.73m2, and lower serum levels of BNP or NT-proBNP (1.6%).

Patient characteristics by eligibility status are shown in Figure 2.

Conclusion

In a large contemporary real-world cohort of patients with HF and LVEF ≥40%, approximately 45,5% would be eligible for finerenone according to the FINEARTS-HF trial selection criteria.Diagram of the selected study populationFor image description, please refer to the figure legend and surrounding text.Patients characteristics by eligibilityFor image description, please refer to the figure legend and surrounding text.