Finerenone showed different effectiveness and safety profiles compared with steroidal mineralocorticoid receptor antagonists (MRAs) across cardio-renal-metabolic phenotypes. This real-world analysis, published in the Current Problems in Cardiology, evaluated the effectiveness and safety of finerenone, a non-steroidal MRA, compared with steroidal MRAs, including spironolactone and eplerenone.

Using the TriNetX global health research network, adult patients initiating MRA therapy were identified. Patients receiving finerenone were treated concurrently with sodium–glucose cotransporter-2 inhibitors (SGLT2i). Study populations were stratified into five cohorts: heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), chronic kidney disease (CKD), diabetes mellitus (DM), and non-DM. Eligible participants included adults initiating these therapies. Pairwise 1:1 propensity score matching was applied to balance baseline characteristics.

In heart failure cohorts, finerenone was associated with reduced heart failure events compared with steroidal MRAs (HFrEF: HR 0.75; HFpEF: HR 0.62; p<0.001 for both), with no significant differences in overall survival or other cardiovascular outcomes. A trend toward increased hyperkalemia risk was observed with finerenone (HFrEF: HR 1.42, p=0.103; HFpEF: HR 1.41, p=0.057). In contrast, across CKD, DM, and non-DM cohorts, finerenone was associated with reduced mortality and cardiovascular events. Additionally, finerenone demonstrated lower risk of acute kidney injury and reduced hyperkalemia risk in CKD and non-DM populations.

These findings are hypothesis-generating and support phenotype-specific selection of MRAs pending further prospective validation.