What are the treatment recommendations based on the FINEARTS (Failure Intervention following Neurological Events: Assessment of Risks and Treatment Strategies) trial for patients with heart failure?

Treatment Recommendations Based on the FINEARTS-HF Trial for Heart Failure Patients

Finerenone, a non-steroidal mineralocorticoid receptor antagonist (MRA), has shown promising results in the FINEARTS-HF trial for patients with heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF), demonstrating benefits in cardiovascular outcomes and albuminuria reduction.

Overview of FINEARTS-HF Trial

The FINEARTS-HF trial evaluated finerenone versus placebo in patients with:

• Heart failure with LVEF ≥40% (including both HFmrEF and HFpEF)
• Symptomatic heart failure (NYHA class II-IV)
• Elevated natriuretic peptide levels
• Evidence of structural heart disease 1, 2

Treatment Recommendations Based on Heart Failure Type

For Heart Failure with Reduced Ejection Fraction (HFrEF)

1. First-line therapy:

   • ACE inhibitor + beta-blocker as foundation therapy 3
   • These medications reduce mortality and hospitalization risk

2. Add-on therapy for symptomatic patients:

   • MRA (spironolactone/eplerenone) for patients who remain symptomatic despite ACE-I and beta-blocker 3
   • Consider sacubitril/valsartan to replace ACE-I in patients who remain symptomatic despite optimal treatment 3

3. Diuretic therapy:

   • Loop diuretics for symptomatic relief of congestion 3
   • Thiazides only if GFR >30 mL/min 4

For Heart Failure with Mildly Reduced or Preserved EF (HFmrEF/HFpEF)

Based on the FINEARTS-HF trial:

1. Consider finerenone:

   • For patients with HFmrEF/HFpEF (LVEF ≥40%)
   • Particularly beneficial for those with albuminuria
   • Finerenone reduced UACR by 30% and decreased risk of new-onset microalbuminuria by 24% and macroalbuminuria by 38% 5

2. Standard therapy:

   • Diuretics for symptom relief and congestion management 3
   • Treatment of hypertension (if present) 3
   • Beta-blockers to control heart rate, especially with atrial fibrillation 3
   • ACE inhibitors for hypertension control and potential benefits on relaxation 3

Management of Comorbidities

Atrial Fibrillation

• Consider electrical cardioversion for persistent atrial fibrillation 3
• For rate control:
  • Beta-blockers as first choice
  • Digoxin for symptomatic patients
  • Avoid diltiazem/verapamil in HFrEF 3

Hypertension

1. Optimize ACE inhibitors, beta-blockers, and diuretics
2. Add MRAs or ARBs if not already prescribed
3. Consider second-generation dihydropyridine derivatives if needed 3

Angina

1. Optimize beta-blocker therapy
2. Consider coronary revascularization
3. Add long-acting nitrates
4. Consider second-generation dihydropyridine derivatives if needed 3

Monitoring and Follow-up

• Regular monitoring of renal function and electrolytes:
  • Before starting therapy
  • 1-2 weeks after each dose increase
  • At 3 months and then every 6 months 4
• Monitor for hyperkalaemia, especially when combining MRAs with ACE inhibitors 4
• Finerenone may cause an initial decline in eGFR (-2.9 mL/min/1.73 m²) but does not significantly alter chronic eGFR slope 5

Important Cautions

• Avoid combining ARBs with both ACE inhibitors and MRAs due to increased risk of renal dysfunction and hyperkalemia 3
• Avoid diltiazem or verapamil in HFrEF as they increase risk of worsening heart failure 3
• Use diuretics cautiously in HFpEF to avoid excessive preload reduction 3
• Finerenone should be used with caution in patients with advanced kidney disease (eGFR <25 mL/min/1.73 m²) 2

Comprehensive Care

• Implement non-pharmacological intervention programs to improve quality of life and reduce readmissions 3
• Consider specialized heart failure clinics, nurse specialists, or telemonitoring based on disease stage and available resources 3
• Adapt care organization to patient needs and available resources 3

Prevention of Worsening Heart Failure

• Early and rapid administration of guideline-recommended medical therapy is essential for preventing first and recurring episodes of worsening heart failure 6
• Optimize doses of ACE inhibitors, beta-blockers, and MRAs to target doses when possible 4

The FINEARTS-HF trial represents an important advancement in the treatment of HFmrEF/HFpEF, offering a new therapeutic option with finerenone that shows promise in reducing cardiovascular events and providing kidney protection through albuminuria reduction.