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Advancing Heart Failure Care With MRAs

CE / CME

Advancing Heart Failure Care With Steroidal and Nonsteroidal Mineralocorticoid Receptor Agonists

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Nurse Practitioners/Nurses: 1.00 Nursing contact hour

Physicians: maximum of 1.00 AMA PRA Category 1 Credit

Released: June 17, 2025

Expiration: June 16, 2026

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Patient Case 1

Let us dive into addressing the clinical gaps that exist in HF management. As previously mentioned, large observational data sets and registries have established the crucial gap of underutilizing recommended risk-reducing therapies. As a result, patients will face increased risks that they otherwise would not. Where possible in patients eligible for therapy, HCPs should do everything within their power to get patients on effective GDMT quickly after diagnosis and titrate to the target doses that were evaluated in key clinical trials.

To illustrate these gaps, our patient case is a 68-year-old man with HFmrEF, LVEF of 43%, and a history of CKD (eGFR: 40 mL/min/1.73m2), T2D, and HTN. Again, this shows the multimorbidity that exists in patients with HF. The patient’s current medications include a beta-blocker, SGLT2 inhibitor, ACE inhibitor, and loop diuretic. In addition, the patient has NYHA Class II functional status, a stable weight, and mild fatigue with exertion. His potassium is 4.6 mmol/L, hemoglobin A1C is 7.3%, and serum creatinine is 1.8 mg/dL.

There are probably several opportunities that exist for this patient. There are multiple therapeutic classes that should be considered and the below normal ejection fraction invites the question of a change from ACE inhibitor to an ARN inhibitor. This patient is not being treated with an MRA. There also is increasing data that support the potential of adding a GLP-1 receptor agonist to address both the CKD and HF.33

I think this patient case highlights the common gaps in HF care. In fact, there are multiple therapeutic classes that could be added or switched to in order to achieve the best possible outcomes for this patient. I will also add that the data from the FINEARTS-HF trial support the addition of a nonsteroidal MRA. This patient also has T2D and CKD, as benefits with finerenone have been shown.34

What would be your next step in optimizing therapy for this patient?

Would a nonsteroidal MRA be appropriate for this patient given his comorbidities and current therapy?

Patient Case 1 Continued

Regarding poll question 4, option A is wrong because there are multiple opportunities that can improve the therapeutic regimen to bring about improved outcomes. Option E is incorrect because this patient, who has a NYHA Class II functional status, would have been included in multiple trials of therapies that could produce additional benefit.

Therefore, we are left with options B, C, and D. An argument can be made to add spironolactone based on the TOPCAT trial. I would argue that the more recent data from FINEHEARTS-HF provide support for using a nonsteroidal MRA like finerenone. It would not be wrong to refer this patient to a nephrologist but from my perspective, option C is probably the best answer—adding a nonsteroidal MRA.

For the poll question 5, option D is reasonable because you would have the benefit of having multiple stakeholders involved. It always is helpful to me to be able to reach out to colleagues and have them weigh in on patient care. I also would argue that the patient does not have hyperkalemia or prohibitive renal dysfunction, so I do not like option B. Option C could work, but we have decent longer-term data that substantiate the benefit of using an MRA in patients with comorbid CKD. Of all the options, I like A the most. The patient may benefit from the improved selectivity of a nonsteroidal MRA vs a steroidal MRA. Again, data from the FINEARTS-HF trial support the use of finerenone in a patient like this.

Patient Case 2

Our second patient case is a 74-year-old woman with HFpEF. Her LVEF is 55% and her blood pressure is elevated. She has comorbid obesity, HTN, and dyslipidemia. She is on a beta-blocker, SGLT2 inhibitor, and ARN inhibitor, but is limited by NYHA Class III symptoms, including dyspnea with minimal exertion and mild leg swelling. She has been hospitalized twice in the last 6 months for HF exacerbations.

The patient’s potassium is 4.2 and her LDL is 120 mg/dL. Something more needs to be done to help her. I would strongly argue that improved blood pressure control and weight loss will go a long way. What are the other potential complimentary ways in which she could be helped?

Would you consider integrating a nonsteroidal MRA into her treatment plan?

What additional information would help guide your next therapeutic decision for this patient?

Patient Case 2 Continued

For poll question 6, I would argue that all of these are important. One is probably no more important than another; these are complimentary data points that can help HCPs round out their understanding of the patient and their limitations, which could be physical and social. For this patient, there are potential additional therapeutic options. This is a patient that could have been included in the FINEARTS-HF trial, which supports the use of a nonsteroidal MRA.

In addressing poll question 7, an MRA in a patient like this could help achieve blood pressure control through a mechanism of action that also reduces fibrosis, inflammation, and fluid accumulation. Then a strong argument can be made to achieve better blood pressure control since the elevated blood pressure could be a major driver of the repeated HF hospitalizations.

I will acknowledge that there is a lack of strong mortality data in HFpEF, and the FINEARTS-HF trial did not establish a statistically significant reduction in cardiovascular mortality. Rather, the benefit of the primary composite endpoint was driven by a reduction in the HF events that were nonfatal.

Option D is a real concern, and I would love to see more therapies come forth that can improve HF hospitalization and worsening HF events as well as reduce cardiovascular and all-cause mortality. I think options A and B are reasonable. If after confirming renal function by looking at her potassium via close monitoring, is this someone who is still eligible for initiation of an MRA? And unequivocally, her recent HF hospitalizations do reinforce her high-risk status.

Key Takeaways

In summary, there are significant and persistent unmet needs in HF management, especially considering patients with HFmrEF or HFpEF lack as many established and evidence-based therapies that we have for managing HFrEF.

The most recent HF guidelines discuss the 4 core pillars of HF therapy, and we now have many more of those, including Class I/II recommended therapies. Spironolactone is associated with reduced HF hospitalization in patients from the Americas vs other global regions. Those benefits were particularly notable in patients with HFpEF and resistant HTN. Finerenone offers the advantages of greater selectivity, potential for less off-target effects, and a significant reduction in the composite of cardiovascular death and worsening HF events in HFmrEF and HFpEF. This offers a new treatment option for those with comorbid T2D and CKD.

There are barriers to MRA use, including clinical inertia. Some HCPs do not think of using an MRA across the entire ejection fraction spectrum, inclusive of patient populations where there are stronger data showing mortality benefit. It also is important to closely monitor patients on MRAs in terms of their renal function and hyperkalemia risk to ensure we can address hyperkalemia or worsening of renal function early. As of today, based on current guidelines, MRAs have a class IIb recommendation. The hope is that the FINEARTS-HF trial helps to embolden or strengthen the recommendation for MRAs, in particular, nonsteroidal MRAs, use in this patient population.

Which of the following correctly illustrates current treatment of HFmrEF/HFpEF?

Based on the latest clinical trials, what is a key safety advantage of finerenone compared to steroidal MRAs in patients with HFmrEF/HFpEF?

A 72-year-old woman with HFpEF (LVEF: 56%), CKD (eGFR: 48 mL/min/1.73 m²), HTN, and T2D is symptomatic despite optimal GDMT, including diuretics and an SGLT2 inhibitor. Recent labs show potassium of 4.8 mEq/L. Given the latest clinical trial evidence, what is the most appropriate next step to enhance her HF management?