Finerenone Expands MRA Options as Pharmacists Address Underrecognized HFpEF

Dan Landup, PharmD, HF-Cert, a heart failure and cardiovascular clinical pharmacist with Advocate Medical Group in Chicago, Illinois, describes heart failure with preserved ejection fraction (HFpEF) as a clinical syndrome rather than a single disease state. It typically comes with comorbidities such as hypertension, diabetes, atrial fibrillation, chronic kidney disease, and obesity, which he says helps explain higher outpatient and pharmacy costs. He adds that HFpEF often goes unrecognized, especially in primary care and rural settings. Clinicians may believe symptoms are related to other comorbidities or deconditioning, there are no standardized diagnostic criteria, and a normal ejection fraction or normal natriuretic peptide levels can end the workup too early.

Landup calls finerenone (Kerendia; Bayer Healthcare) one of his first-line agents for patients with HFpEF, as long as they can access and afford it. He points to the clear benefit shown in FINEARTS-HF (NCT04435626), a more favorable adverse effect profile without the hormonal effects of spironolactone (Aldactone; Pfizer), and use at lower kidney function (estimated glomerular filtration rate down to 25 vs 30 for spironolactone). He notes that the American College of Cardiology’s expert consensus decision pathway now names finerenone as the preferred mineralocorticoid receptor antagonist (MRA). He notes that the spironolactone evidence from TOPCAT (NCT00094302) and SPIRIT-HF (NCT04727073) should be read with caution, but the treatment remains a reasonable choice when cost or access rules out finerenone.

He encourages pharmacists not to wait for a dedicated heart failure clinic. They can use existing primary care and chronic disease management workflows to find patients with the HFpEF phenotype, close gaps in guideline-directed medical therapy, and gradually build a patient panel. Because HFpEF is now the predominant and rising phenotype in the United States, with outcome risks similar to those of heart failure with reduced ejection fraction, Landup says it deserves the same urgency. He describes an sodium-glucose cotransporter 2 inhibitor plus a nonsteroidal MRA as the standard of care and calls for coordinated management across the cardio-kidney-metabolic continuum.