Interplay of serum potassium and kidney function with finerenone in heart failure with mildly reduced or preserved ejection fraction: findings from FINEARTS ‐ HF (original) (raw)

Ferreira, J. P. et al. (2025) Interplay of serum potassium and kidney function with finerenone in heart failure with mildly reduced or preserved ejection fraction: findings from FINEARTS ‐ HF.European Journal of Heart Failure, (doi: 10.1002/ejhf.70052) (PMID:41039732) (Early Online Publication)

Abstract

Aims: Finerenone improved heart failure (HF) outcomes in patients with heart failure and mildly reduced or preserved ejection fraction (HFmrEF/HFpEF). Clinical decision‐making around initiation of mineralocorticoid receptor antagonists often relies on measures of kidney function and serum potassium (K + ) levels. The aim of this study was to evaluate the efficacy and safety of finerenone across categories of serum K + and estimated glomerular filtration rate (eGFR). Methods and results: Four mutually exclusive categories were created: (1) K + ≤4.5 mmol/L and eGFR ≥60 ml/min/1.73 m 2 ; (2) K + >4.5 mmol/L and eGFR ≥60 ml/min/1.73 m 2 ; (3) K + ≤4.5 mmol/L and eGFR <60 ml/min/1.73 m 2 ; and (4) K + >4.5 mmol/L and eGFR <60 ml/min/1.73 m 2 . Outcomes and treatment effects were compared across these categories. The primary outcome was a composite of total HF events and cardiovascular death. The median follow‐up was 32 months. A total of 6001 patients were included. Compared to patients with K + ≤4.5 mmol/L and eGFR ≥60 ml/min/1.73 m 2 , those with eGFR <60 ml/min/1.73 m 2 , irrespective of K + levels, had a 1.5‐ to 2‐fold higher risk of experiencing primary outcome and fatal events across treatment groups. No significant interaction was observed on the effects of finerenone (vs. placebo) on the primary outcome across K + /eGFR categories. The respective risk ratios (RR) and 95% confidence intervals (CI) were: (1) K + ≤4.5 mmol/L and eGFR ≥60 ml/min/1.73 m 2 : RR 0.66, 95% CI 0.52–0.85; (2) K + >4.5 mmol/L and eGFR ≥60 ml/min/1.73 m 2 : RR 0.92, 95% CI 0.65–1.30; (3) K + ≤4.5 mmol/L and eGFR <60 ml/min/1.73 m 2 : RR 0.91, 95% CI 0.74–1.13; (4) K + >4.5 mmol/L and eGFR <60 ml/min/1.73 m 2 : RR 0.92, 95% CI 0.72–1.17; p for interaction = 0.20. Patients with low eGFR and/or high K + experienced more frequent adverse events and treatment discontinuation; still, categories of K + /eGFR did not significantly modify the relative risk of adverse events with finerenone versus placebo ( p for interaction > 0.1 for all adverse events). Conclusions: No significant heterogeneity was found on the effect of finerenone to reduce primary outcome events. Still, adverse events and treatment discontinuation were more frequent among patients with low eGFR and/or high K + , suggesting. that such patients may require tailored strategies to mitigate adverse events and avoid treatment discontinuation.

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