Finerenone is NOT a reasonable substitute for spironolactone in HFrEF patients with hypotension
Finerenone lacks established efficacy data in HFrEF and should not replace spironolactone in this population, regardless of blood pressure concerns. The evidence-based approach is to optimize spironolactone dosing or use eplerenone rather than switching to finerenone.
Why Finerenone is Not Appropriate for HFrEF
Lack of Guideline Support and Evidence in HFrEF
Mineralocorticoid receptor antagonists (spironolactone or eplerenone) are Class I, Level A recommendations for all symptomatic HFrEF patients with LVEF ≤35% to reduce mortality and HF hospitalization 1.
Finerenone's evidence base is entirely in different populations: it is indicated for chronic kidney disease associated with type 2 diabetes 1, 2, and more recently demonstrated benefit in HFmrEF/HFpEF (LVEF ≥40%) 3, 4.
The ARTS-HF trial (the only study examining finerenone specifically in HFrEF) was a phase 2b dose-finding study that measured NT-proBNP reduction, not mortality or hospitalization outcomes 5, 6. This is insufficient evidence to support substitution for proven therapies.
No major HF guidelines (ESC 2016, ACC/AHA 2022) recommend finerenone for HFrEF 1.
Managing Hypotension in HFrEF Patients on MRAs
The Blood Pressure Concern is Misplaced
MRAs (spironolactone and eplerenone) rarely cause hypotension 1. They are among the HF medications least likely to lower blood pressure, unlike ACE inhibitors, ARBs, ARNIs, and beta-blockers 1.
In the 2022 ACC/AHA guidelines, patients with HFrEF and low systolic blood pressure (even <110 mmHg) still benefited from and tolerated MRAs 1. The PARADIGM-HF analysis showed that patients with lower baseline blood pressure had equivalent tolerance and relative benefit 1.
Appropriate Management Strategy for Low Blood Pressure
When a HFrEF patient has hypotension, the priority should be:
Assess congestion status first - use clinical examination, daily weights, and consider lung/cardiac ultrasound 1. If euvolemic, reduce diuretics rather than stopping MRAs 1.
Distinguish symptomatic from asymptomatic hypotension - asymptomatic low blood pressure alone is not a reason to withhold or reduce guideline-directed medical therapy 1.
If symptomatic hypotension occurs, adjust medications in this order of priority 1:
- First: Reduce or eliminate diuretics if not congested
- Second: Consider down-titrating ACE inhibitors/ARBs/ARNIs or beta-blockers
- Last resort: Reduce MRA dose (but do not discontinue)
Initiate SGLT2 inhibitors, which can facilitate MRA use - SGLT2 inhibitors reduce hyperkalemia risk and rarely cause hypotension, making it easier to maintain MRA therapy 1.
If MRA Truly Cannot Be Tolerated
Switch to eplerenone if spironolactone causes side effects (though hypotension is rarely the issue - hyperkalemia and gynecomastia are more common) 1.
Use lower doses of spironolactone (12.5-25 mg daily) rather than discontinuing 1. Even suboptimal doses provide some benefit.
If MRA must be stopped, substitute with an ARB if not already on one 1, though this is inferior to MRA therapy for mortality reduction in HFrEF.
Critical Pitfall to Avoid
The most common error is prematurely discontinuing proven life-saving HFrEF therapies due to asymptomatic low blood pressure readings 1. Nearly half of HFrEF patients receive no changes to GDMT despite being on suboptimal doses, often due to unfounded concerns about blood pressure 1. Withdrawal of GDMT is associated with worse clinical outcomes 1.
Finerenone should only be considered in HFrEF patients who also have CKD with type 2 diabetes (as an addition to, not replacement for, standard MRA therapy) 1, or in patients with HFmrEF/HFpEF where it now has established evidence 3, 4.