Finding New Pillars of Care for HFpEF

The entire treatment paradigm—indeed, the entire language—surrounding heart failure (HF) with a reduced ejection fraction (HFrEF), has evolved significantly in recent years. With the deployment of SGLT2 inhibitors in HFrEF, the HF community started referring to the 4 pillars of care for this condition. Each pillar represents 1 of the key lifesaving medications that need to be prescribed to all patients to ensure optimal outcomes. Similar language has very recently evolved in the management of chronic kidney disease (CKD), which now includes 4 pillars as well. One of these pillars is a novel medication finerenone, which is a nonsteroidal mineralocorticoid receptor antagonist.

Unfortunately, HFrEF is still a relatively pillar-less condition. Only the SGLT2 inhibitors have proven effective in reducing rates of mortality/hospitalization for HF in this cohort of patients. In this installment of Talking Therapeutics, we explore whether the novel medication finerenone, which has demonstrated benefit in patients with kidney disease, can also improve outcomes in patients with HFpEF.

Talking Point: Clear Signal for Benefit

The FINEARTS-HF trial was an international, double-blind trial, randomized study that included hpatients with HF and a left ventricular ejection fraction of 40% or greater. Patients received either finerenone (at a maximum dose of 20 mg or 40 mg once daily) or matching placebo. The primary outcome was a composite of total worsening HF events (with an event defined as a first or recurrent unplanned hospitalization or urgent visit for HF) and death from cardiovascular causes.

This trial showed that the number of worsening HF events was 842 in the finerenone group and 1024 in the placebo group (RR, 0.82; 95% CI, 0.71 to 0.94; P = 0.006). The percentage of patients who died from cardiovascular causes was 8.1% and 8.7%, respectively (HR, 0.93; 95% CI, 0.78 to 1.11). Finerenone was associated with an increased risk of hyperkalemia and a reduced risk of hypokalemia.

Talking Point: Consider Finerenone for HFpEF

Given that this study was a randomized, contemporary clinical trial, I am comfortable recommending finerenone as a therapy for patients with HFpEF (and HFmrEF) who do not have contraindications for this therapy. I think that cost must be factored, as this drug will be on patent and will impart a higher copay. Additional pharmacoeconomic data would be helpful in to determine if this added cost is warranted in relation to the clinical benefits of finerenone for HFpEF.