Heart failure patients with mildly reduced (HFmrEF) or preserved ejection fraction (HFpEF) often have kidney issues too. These raise risks for worse outcomes like hospital stays and death. The FINEARTS-HF trial tested if finerenone, a non-steroidal mineralocorticoid blocker, works the same way no matter the kidney risk. The study results were published in Journal of the American College of Cardiology: Heart Failure.
This pre-planned analysis divided 5,797 patients (97% of the total) into low (35%), moderate (29%), and high/very high (36%) kidney risk groups using KDIGO guidelines. All had eGFR over 25 mL/min/1.73m² and potassium under 5.0 mmol/L at start. Follow-up ran 2.7 years on average. The researchers wanted to know: does kidney status change finerenone's punch?
Kidney Risk Ties to More Heart and Kidney Trouble
Higher kidney risk meant more trouble across the board. The main outcome, the CV death plus first and repeat heart failure events, climbed with risk level. New atrial fibrillation, vascular problems, and a kidney composite (like eGFR drop or end-stage disease) were increased. Baseline splits showed real-world mix—35% low, 36% high/very high. This mirrors HFpEF/HFmrEF patients where kidneys often lag.
Finerenone Delivers Steady Wins on Key Goals
Finerenone beat placebo on the primary endpoint no matter the kidney risk (Pinteraction=0.24). Rates dropped consistently with fewer CV deaths and HF events across low, moderate, and high groups. Heart failure health status improved too, per Kansas City Cardiomyopathy Questionnaire symptom scores at 12 months (Pinteraction=0.36). Patients felt better, regardless of kidneys.
Bonus on Kidneys, No Safety Scares
High-risk patients saw bigger drops in urine albumin-to-creatinine ratio after 6 months (Pinteraction=0.031)—key for slowing kidney decline. eGFR slopes stayed steady, no worsening. Safety held firm: hyperkalemia risks matched placebo levels, even in high-risk cases. No excess potassium spikes or other red flags. 
Real-World Shift for HF Care
The next HFpEF patient with eGFR 30 and albuminuria? Finerenone fits, cutting events and symptoms without kidney worry. FINEARTS-HF builds on FIDELIO/FIGARO CKD data, proving broad use in HF. Low-risk patients gain too—no harm in starting early. Guidelines may soon list it routinely, pairing with SGLT2s and ARNi. Cost-effective, once-daily pill. Trials excluded sickest kidneys, so monitor in patients below 25 mL/min.