Abstract 4356836: Finerenone Versus Spironolactone in Patients With Heart Failure With Preserved Ejection Fraction: A Real-World Comparative Analysis

Background: Heart failure with preserved ejection fraction (HFpEF) remains a major therapeutic challenge with limited pharmacologic options that improve outcomes. While mineralocorticoid receptor antagonists such as spironolactone are widely used, finerenone, a newer nonsteroidal agent, has shown potential in reducing cardiovascular and renal events. Real-world comparative data between these agents in HFpEF are limited. Purpose: To compare clinical outcomes including hospitalization, mortality, acute kidney injury (AKI), and hyperkalemia in HFpEF patients treated with finerenone versus spironolactone. Methods: A retrospective cohort analysis was conducted using the TriNetX electronic health record network from 101 healthcare organizations. Adult patients with HFpEF treated with finerenone (n = 809) or spironolactone (n = 179,566) were identified. After 1:1 propensity score matching, each cohort included 796 patients. Patients with systolic heart failure were excluded. Outcomes assessed over 12 months included all-cause hospitalization, mortality, AKI, and hyperkalemia. Odds ratios (OR), 95% confidence intervals (CI), p-values, and Kaplan-Meier survival analyses were used for statistical evaluation. Results: Finerenone use was associated with significantly lower hospitalization (30.0% vs. 42.1%; OR 0.590, 95% CI: 0.480–0.726; p < 0.001), mortality (3.8% vs. 11.9%; risk difference –8.1%, 95% CI: –10.7 to –5.5; p < 0.001), AKI (22.0% vs. 28.3%; OR 0.715, 95% CI: 0.569–0.898; p = 0.004), and hyperkalemia (9.4% vs. 15.5%; OR 0.569, 95% CI: 0.419–0.773; p < 0.001) compared to spironolactone. Kaplan-Meier curves demonstrated improved one-year hospitalization-free survival (61.4% vs. 51.8%; p < 0.001) and overall survival (94.7% vs. 85.8%; p < 0.001), with a mortality hazard ratio of 0.358 (95% CI: 0.237–0.540). Conclusion: In this real-world study of HFpEF patients, finerenone was associated with lower rates of hospitalization, mortality, AKI, and hyperkalemia compared to spironolactone. These findings suggest that finerenone may offer a safer and more effective alternative in HFpEF management. Prospective studies are needed to validate these results.