Mineralcorticoid receptor (MR) blockade is a mainstay of treatment for heart failure with reduced ejection fraction (HFrEF); however, the benefit is less well established in heart failure with mildly reduced ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF). The TOPCAT study failed to demonstrate a reduction in cardiovascular mortality and heart failure (HF) hospitalizations in this population but suggested potential benefits of mineralocorticoid receptor antagonists (MRAs) in specific patients subgroups. The FINEARTS-HF study, which evaluated the non-steroidal MRA finerenone in patients with HFmrEF or HFpEF, demonstrated a significant reduction in the primary composite endpoint of cardiovascular death and events related to worsening of heart failure (WHF), primarily driven by a decrease in total WHF events. Moreover, the FINEARTS-HF study demonstrated consistent efficacy across the entire left ventricular ejection fraction (LVEF) spectrum, regardless of sodium–glucose cotransporter 2 inhibitors use, sex, or age, with an early onset of benefit and a favourable safety and tolerability profile. Finerenone is currently indicated in class I in diabetic patients with chronic kidney disease to reduce the risk of HF; in light of the FINEARTS-HF results, it could become a new pillar of therapy for patients with HFpEF and HFmrEF.

Mineralocorticoid receptor antagonism represents a therapeutic cornerstone in patients with HFrEF. However, the efficacy of MRAs in patients HFmrEF or HFpEF remains unclear. While the TOPCAT trial did not demonstrate a statistically significant reduction in cardiovascular mortality or hospitalizations for HF in this patient population, post hoc data suggested potential clinical benefits of MRAs in specific patient subgroups. More recently, the landscape has evolved with the FINEARTS-HF trial, which generated novel evidence regarding finerenone, a non-steroidal MRA, in the HFmrEF and HFpEF cohorts. This investigation established a statistically significant decrease in the primary composite endpoint, comprising cardiovascular death and worsening heart failure events. This positive outcome was principally attributable to a lower incidence of total WHF events. Key findings also highlighted the therapy’s rapid onset of action and favorable safety profile. Notably, finerenone’s benefit was consistent across the entire LVEF spectrum and was not influenced by baseline SGLT2i use, sex, or age. Finerenone’s established indication is for patients with type 2 diabetes mellitus and chronic kidney disease to reduce heart failure risk. However, based on the findings of the FINEARTS-HF trial, finerenone may represent a novel therapeutic pillar for patients with HFpEF and HFmrEF. In this review, we aim to describe the potential benefits of MRAs in the pathophysiology of HFpEF and HFmrEF and in different patient phenotypes, the results of the FINEARTS-HF trial, and the most important subanalyses of the study.