Patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) are at high risk of developing atrial fibrillation or atrial flutter (AFF). In a prespecified exploratory analysis of the FIDELIO-DKD trial, the effect of finerenone, a novel mineralocorticoid receptor antagonist (MRA), on new-onset AFF was evaluated. The trial also provided insight into the effect of finerenone on primary and secondary cardiorenal outcomes stratified by AFF status.

In this prospective randomized trial, 5,674 patients with CKD and T2D were randomized to treatment with finerenone or placebo. During a median 2.6-year follow-up, new-onset AFF occurred in 3.2% of patients on finerenone and in 4.5% of patients receiving placebo, which correlated with a 29% reduction in AFF risk (P=0.0164). The trial also revealed that risk of new-onset AFF was not modified by underlying demographics or baseline cardiometabolic parameters or therapies. Data further suggested that finerenone has beneficial effects on kidney and cardiovascular outcomes, regardless of underlying history of AFF.

Earlier MRA trials have shown that MRA slightly reduces risk of AFF. It was reasonable to test the hypothesis that this novel selective MRA might further decrease the risk of AFF in high-risk patients with CKD and T2DM. Because patients infrequently underwent electrocardiogram evaluation, the possibility exists that asymptomatic cases of AFF may have been missed. Given the small percentage in reduction of AFF in the FIDELIO-DKD trial, it may be difficult for clinicians to immediately embrace finerenone for the sole purpose of primary prevention for AFF. Larger prospective studies focused on new onset AFF are required to confirm or refute these findings, including from the FIGARO-CKD trial of finerenone.

The treatment options for diabetes are rapidly expanding, and it would be outstanding if such medications could concomitantly and significantly lower the risk of new onset AFF, a common and costly condition that commonly accompanies diabetes kidney disease.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Prevention, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: ACC Annual Scientific Session, ACC21, Diabetes Mellitus, Diabetes Mellitus, Type 2, Metabolic Syndrome, Prospective Studies, Mineralocorticoid Receptor Antagonists, Atrial Flutter, Atrial Fibrillation, Follow-Up Studies, Naphthyridines, Diabetic Nephropathies, Renal Insufficiency, Chronic, Kidney, Primary Prevention, Electrocardiography, Demography

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