From Evidence to Execution: Pharmacists Navigate MRA Selection and Access in HFpEF and HFmrEF

Author(s)Ryu Kariyawasam-Chavez, Content Associate

Fact checked by: Ron Panarotti

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Key Takeaways

SGLT2 inhibitors hold class 2a recommendations in HFpEF/HFmrEF, while MRAs, ARBs/ACEIs, ARNIs, and β-blockers are class 2b options requiring individualized integration across comorbid disease domains.
Finerenone reduced total worsening HF events plus cardiovascular death versus placebo (RR 0.84) in FINEARTS-HF, but lacked active-comparator data against spironolactone and did not significantly lower cardiovascular mortality.
Nonsteroidal MRA selection may favor finerenone to avoid spironolactone-associated hormonal adverse effects, whereas spironolactone remains advantageous for familiarity, cost, and additional blood pressure lowering.
Hyperkalemia risk and renal thresholds necessitate protocolized potassium/eGFR surveillance (baseline, 4 weeks post-start, post-titration, then periodically) with label-concordant dose modification despite conservative alert-driven practices.
Medication affordability, prior-authorization infrastructure, and discharge-to-outpatient continuity (reconciliation, education, Meds-to-Beds, longer fills, early follow-up) often determine real-world persistence more than efficacy alone.

The panelists emphasized that selecting a therapy is only one step toward improving outcomes for patients with heart failure.

As treatment options expand for heart failure with preserved ejection fraction (HFpEF) and mildly reduced ejection fraction (HFmrEF), pharmacists are increasingly responsible for translating clinical evidence into individualized, sustainable care. In a recent Pharmacy Times Clinical Forum in Atlanta, Georgia, moderator Dejan Landup, PharmD, HF-Cert, a heart failure and cardiometabolic clinical pharmacist with Advocate Medical Group, led a panel of health system pharmacists in discussing mineralocorticoid receptor antagonist (MRA) selection, laboratory monitoring, medication access, and continuity between inpatient and outpatient settings. Although the approval of finerenone (Kerendia; Bayer) has added another treatment option for patients with left ventricular ejection fraction (LVEF) of 40% or greater, the discussion demonstrated that selecting a therapy is only one step toward improving outcomes.

How Is the Treatment Landscape Evolving?

Under the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America guidelines, sodium-glucose cotransporter 2 inhibitors have a class 2a recommendation in HFmrEF and HFpEF. In HFmrEF, angiotensin receptor-neprilysin inhibitors (ARNIs), angiotensin-converting enzyme inhibitors, angiotensin receptor blockers (ARBs), MRAs, and β-blockers carry class 2b recommendations. For selected patients with HFpEF, MRAs, ARBs, and ARNIs may also be considered, particularly among those with LVEF closer to 50%. Diuretics are recommended to relieve congestion in patients with fluid retention.¹

Applying these recommendations can be complicated by the overlapping cardiac, kidney, and metabolic conditions commonly observed in HFpEF. Pharmacists may need to coordinate treatment decisions across cardiology, nephrology, and primary care rather than allowing responsibility for initiation to move indefinitely between specialties.

Alexandria May, PharmD, BCPS, a clinical pharmacist manager in ambulatory care at Grady Health System, described placing cardiology and nephrology clinicians in the same message when each service deferred a treatment decision to the other. Her approach was direct: “I’ll put them both in a message, and [I’ll say], ‘Well, they’re here right now. I’m going to start them on [dapagliflozin (Farxiga; AstraZeneca)]. Is everybody cool with that?’”

How Does Finerenone Affect MRA Selection?

In July 2025, the FDA expanded the indication for finerenone to reduce the risk of cardiovascular death, HF hospitalization, and urgent HF visits in adults with HF and LVEF of 40% or greater.² The approval followed results from the phase 3 FINEARTS-HF trial (NCT04435626), which randomly assigned 6001 patients with symptomatic HF and LVEF of 40% or greater to finerenone or placebo.³

Finerenone produced an approximately 16% reduction in the composite of total worsening HF events and cardiovascular death compared with placebo (rate ratio [RR], 0.84; 95% CI, 0.74-0.95; P = .007). The result was primarily driven by an 18% reduction in total worsening HF events (RR, 0.82; 95% CI, 0.71-0.94; P = .006). Cardiovascular death occurred in 8.1% of patients receiving finerenone and 8.7% receiving placebo and was not significantly reduced (HR, 0.93; 95% CI, 0.78-1.11).³

“I wish [finerenone] had been compared to spironolactone and not a placebo,” Kathy Tang, PharmD, a clinical pharmacy specialist in cardiology at Wellstar Kennestone Regional Medical Center in Marietta, Georgia, said during the discussion. “It just doesn’t tell me a whole lot about how it holds up to industry standards—spironolactone, which is what we’re using now—so it’s hard to say.”

As a nonsteroidal MRA, finerenone does not have the same hormonal adverse effect (AE) profile as spironolactone; however, the panelists emphasized that FINEARTS-HF was placebo-controlled and did not establish superiority over spironolactone. The choice may depend on clinical and practical considerations. Finerenone may be preferred when avoiding hormonal AEs, whereas spironolactone remains familiar and useful when additional blood pressure reduction is desired.

Monitoring Potassium and Kidney Function

Hyperkalemia occurred in 14.3% of patients receiving finerenone and 6.9% receiving placebo in FINEARTS-HF.³Current prescribing information calls for measuring serum potassium and estimated glomerular filtration rate (eGFR) before treatment, 4 weeks after initiation, 4 weeks after dosage adjustments, and periodically thereafter. Initiation is not recommended when eGFR is below 25 mL/min/1.73 m² or serum potassium exceeds 5.0 mEq/L.²

For patients with HF, the current dose may be maintained when potassium is between 5.0 and 5.5 mEq/L. At higher levels, the dose must be decreased or withheld according to the patient’s current dosage and potassium result.²The panel observed that electronic alerts and concern surrounding elevated potassium may nevertheless lead clinicians to respond more conservatively, creating an opportunity for pharmacists to interpret results, arrange follow-up testing, and recommend label-concordant adjustments.

Can Patients Obtain and Continue Therapy?

Affordability and administrative burden often influence whether an evidence-supported regimen becomes sustainable. Participants described varying levels of medication-access infrastructure. Some pharmacists personally complete prior authorizations and connect patients with assistance programs, whereas other health systems employ care coordinators or pharmacist-
supervised technicians.

Despite finerenone’s efficacy, Adele Robbins, PharmD, BCCP, a cardiothoracic surgery intensive care unit clinical pharmacy specialist at Emory Saint Joseph’s Hospital, said that accessibility might favor spironolactone for patients with limited resources. “I can confidently say I’m pretty sure they’re going to get spironolactone. They’re not going to run into barriers getting that.”

The observation highlights pharmacists’ role in evaluating affordability before discharge rather than discovering later that a patient cannot continue treatment.

Strengthening Transitions of Care

Panelists identified medication initiation before discharge, medication reconciliation, patient education, and communication with outpatient teams as important opportunities for pharmacists. Institutional strategies included Meds to Beds programs, longer discharge prescriptions, early follow-up, and electronic health record tools designed to identify patients who may be eligible for optimization. These approaches were not uniform across participating institutions, underscoring the importance of adapting workflows to local staffing and resources.

The panel ultimately framed expansion of pharmacist-led care as both a clinical and organizational goal. As Justin Joy, PharmD, BCCP, cardiology clinical pharmacy specialist at Emory Healthcare, said, advocating for “more pharmacists practicing at the top of their license” is central to ensuring that emerging evidence translates into measurable improvements in HF care.