Finerenone may offer a safer alternative to steroidal mineralocorticoid receptor antagonists in patients with cancer and heart failure. A retrospective observational analysis published in the American Journal of Cardiology evaluated the comparative effectiveness of finerenone versus spironolactone using the TriNetX database. 
The study included adults with a history of cancer and heart failure with baseline left ventricular ejection fraction (LVEF ≥40%) who initiated mineralocorticoid receptor antagonist (MRA) therapy. These findings address a clinically relevant gap in selecting MRAs in patients with elevated risks of hyperkalemia and heart failure events.

Patients were followed for one year after treatment initiation. After 1:1 propensity score matching, 872 patients were analyzed, with a mean age of 72 years; 45% were female, 50% were White, 23% were receiving chemotherapy, 69% had chronic kidney disease (CKD), and 90% had diabetes.

Compared with spironolactone, finerenone use was associated with a lower risk of heart failure exacerbation (hazard ratio [HR] 0.51; confidence interval [CI] 0.35-0.76), all-cause mortality (HR 0.41; CI 0.21-0.80), severe hyperkalemia (HR 0.57; CI 0.40-0.83), and renal failure (HR 0.71; CI 0.54-0.93). Stroke risk was similar between groups, while composite major adverse cardiovascular events (MACE) were lower with finerenone (HR 0.67; CI 0.51–0.88), with reductions largely reflecting fewer heart failure events.

These findings reflect associations observed within a matched observational cohort over one year. Finerenone use was associated with fewer cardiovascular and renal adverse outcomes compared with spironolactone in this population.