Patients with heart failure (HF) who have worsening HF symptoms that require intensification of oral diuretics in the outpatient setting are common and associated with a poor prognosis, and finerenone reduced the need for intensifying diuretics, according to a secondary analysis of the FINEARTS-HF published Feb. 26 in JAMA Cardiology.

Jonathan W. Cunningham, MD, MPH, FACC, et al., conducted the prespecified analysis of the FINEARTS-HF global, multicenter trial of 6,001 patients (mean age, 72 years; 46% female) with HF with mildly reduced or preserved ejection fraction (LVEF ≥40). Patients were randomized 1:1 to receive 40 mg daily of the nonsteroidal mineralocorticoid antagonist finerenone or placebo. Finerenone resulted in a lower composite rate of worsening HF events and cardiovascular death vs. placebo in the main study.

In this secondary analysis, the authors investigated the frequency and prognostic significance of worsening HF events treated with hospitalization, outpatient intravenous (IV) diuretic administration or oral diuretic intensification, as well as the effect of finerenone vs. placebo on the risk for these events.

Results showed that first worsening HF events included 664 HF hospitalizations, 87 urgent HF visits with IV diuretics and 1,250 oral diuretic intensifications. Mortality rates were higher after worsening HF: 27.7 per 100 patient-years after HF hospitalization, 13.6 after urgent HF visit and 11.6 after outpatient oral diuretic intensification compared to 4.5 per 100 patient-years among patients without worsening HF.

The researchers found that adding outpatient oral diuretic intensification to the primary composite outcome increased the number of first events by 67%. Finerenone was shown to reduce the risk of first outpatient oral diuretic intensification by 11% (95% CI, 0.80-0.98). Additionally, there was a 15% reduction (95% CI, 0.78-0.92) with finerenone in an extended composite outcome of first outpatient oral diuretic intensification, cardiovascular death, HF hospitalization and urgent HF visit.

In an accompanying editorial comment, Gregg C. Fonarow, MD, FACC, et al., write that counting all worsening HF events (including outpatients with HF who need oral diuretic intensification) in future trials "should continue as a testable hypothesis. Yet, as a practical and actionable clinical takeaway," the authors suggest this "should be considered as a sentinel event in disease severity and prognosis, prompting efforts to optimize disease-modifying guideline-directed medical therapies in all eligible patients."