A 55-year-old man with a history of heart failure with preserved ejection fraction (HFpEF; left ventricular ejection fraction [LVEF] 55%) presents for evaluation. He endorses dyspnea on exertion, general fatigue, and labile weight. Recent right heart catheterization findings included right atrial pressure 11 mm Hg and pulmonary wedge pressure 15 mm Hg. His medical history includes coronary artery disease, three coronary artery bypass graft surgeries, hypertension, hyperlipidemia, obstructive sleep apnea, obesity, and a solitary kidney. His medications include aspirin 81 mg once daily, clopidogrel 75 mg once daily, bumetanide 2 mg once daily, dapagliflozin 10 mg once daily, losartan 50 mg once daily, metoprolol tartrate 25 mg twice daily, omeprazole 20 mg once daily, and rosuvastatin 40 mg once daily.
His blood pressure (BP) is 109/74 mm Hg, heart rate (HR) is 71 bpm, and weight in the clinic is 129.9 kg. Laboratory study results include potassium (K+) level 3.9 mEq/L and creatinine (Cr) level 1.2 mg/dL with estimated glomerular filtration rate (eGFR) >60 mL/min/m2.
The correct answer is: C. Add finerenone 20 mg once daily.
Per the product labeling, which considers K+ levels and kidney function, this patient would be prescribed finerenone 20 mg once daily to start.
Evidence from the FINEARTS-HF (Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients With Heart Failure) established the efficacy of finerenone in >6,000 patients with LVEF ≥40% to reduce the risk of cardiovascular (CV) death, hospitalization for heart failure (HF), and urgent HF visits. Finerenone was found to significantly reduce the primary composite endpoint of total worsening HF events and CV death compared with placebo (rate ratio, 0.84; 95% confidence interval, 0.74-0.95; p = 0.007). Compared with steroidal mineralocorticoid-receptor antagonists (MRAs; spironolactone, eplerenone), the nonsteroidal MRA finerenone has potent and selective mineralocorticoid-receptor blockade that helps reduce off-target hormone-related effects. Data from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trial of spironolactone did not prove benefit in the primary endpoint of CV death, aborted cardiac arrest, or hospitalization for the management of HF.
The 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America (AHA/ACC/HFSA) Guideline for the Management of HF designates both angiotensin receptor–neprilysin inhibitors and angiotensin-receptor blockers as Class 2b recommendations. One could consider such a transition if this patient had higher BP parameters. He was taking beta-blocker therapy for an indication other than HFpEF; if he were having adherence concerns, one could consider changing formulations. A change in diuretic therapy would not be indicated at present because he presented with symptoms, labile weight, and relatively stable laboratory parameters.
This patient case quiz is part of the larger Managing HF Across the Spectrum: From Recognizing Symptoms to Implementing Appropriate Treatment initiative, supported by Bayer. To visit the Managing HF Across the Spectrum page and access additional educational activities on this topic, click here.
References
- Harrington JL, Canonico ME, El Rafei A, et al. Nonsteroidal and steroidal mineralocorticoid antagonists: rationale, evidence, and unanswered questions. JACC Heart Fail. 2025;13(10):102637. doi:10.1016/j.jchf.2025.102637
- Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022;79(17):e263-e421. doi:10.1016/j.jacc.2021.12.012
- INSPRA® (eplerenone) tablets, for oral use. Prescribing information (FDA website). Pfizer; 2016. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021437s013lbl.pdf. Accessed 12/10/2025.
- KERENDIA (finerenone) tablets, for oral use. Bayer HealthCare Pharmaceuticals, Inc.; 2025. Available at: https://labeling.bayerhealthcare.com/html/products/pi/Kerendia_PI.pdf. Accessed 12/10/2025.
- Maddox TM, Januzzi JL Jr, Allen LA, et al. 2024 ACC expert consensus decision pathway for treatment of heart failure with reduced ejection fraction: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2024;83(15):1444-1488. doi:10.1016/j.jacc.2023.12.024
- Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003;348(14):1309-1321. doi:10.1056/NEJMoa030207
- Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999;341(10):709-717. doi:10.1056/NEJM199909023411001
- Solomon SD, McMurray JJV, Vaduganathan M, et al. Finerenone in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med. 2024;391(16):1475-1485. doi:10.1056/NEJMoa2407107
- Zannad F, McMurray JJ, Krum H, et al. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 2011;364(1):11-21. doi:10.1056/NEJMoa1009492
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