Abstract Body (Do not enter title and authors here): Background
Heart failure with preserved ejection fraction (HFpEF) remains a major therapeutic challenge with limited pharmacologic options that improve outcomes. While mineralocorticoid receptor antagonists such as spironolactone are widely used, finerenone, a newer nonsteroidal agent, has shown potential in reducing cardiovascular and renal events. Real-world comparative data between these agents in HFpEF are limited.
Purpose
To compare clinical outcomes including hospitalization, mortality, acute kidney injury (AKI), and hyperkalemia in HFpEF patients treated with finerenone versus spironolactone.
Methods
A retrospective cohort analysis was conducted using the TriNetX electronic health record network from 101 healthcare organizations. Adult patients with HFpEF treated with finerenone (n = 809) or spironolactone (n = 179,566) were identified. After 1:1 propensity score matching, each cohort included 796 patients. Patients with systolic heart failure were excluded. Outcomes assessed over 12 months included all-cause hospitalization, mortality, AKI, and hyperkalemia. Odds ratios (OR), 95% confidence intervals (CI), p-values, and Kaplan-Meier survival analyses were used for statistical evaluation.
Results
Finerenone use was associated with significantly lower hospitalization (30.0% vs. 42.1%; OR 0.590, 95% CI: 0.480–0.726; p < 0.001), mortality (3.8% vs. 11.9%; risk difference –8.1%, 95% CI: –10.7 to –5.5; p < 0.001), AKI (22.0% vs. 28.3%; OR 0.715, 95% CI: 0.569–0.898; p = 0.004), and hyperkalemia (9.4% vs. 15.5%; OR 0.569, 95% CI: 0.419–0.773; p < 0.001) compared to spironolactone. Kaplan-Meier curves demonstrated improved one-year hospitalization-free survival (61.4% vs. 51.8%; p < 0.001) and overall survival (94.7% vs. 85.8%; p < 0.001), with a mortality hazard ratio of 0.358 (95% CI: 0.237–0.540).
Conclusion
In this real-world study of HFpEF patients, finerenone was associated with lower rates of hospitalization, mortality, AKI, and hyperkalemia compared to spironolactone. These findings suggest that finerenone may offer a safer and more effective alternative in HFpEF management. Prospective studies are needed to validate these results.