This prespecified secondary analysis of the FINEARTS-HF RCT examined the blood pressure (BP) effects of finerenone vs placebo in 5,999 adults with HFmrEF/HFpEF (mean age 72 years, 45% female, mean baseline SBP 129 mmHg), and whether baseline BP or BP reduction mediated finerenone's cardiovascular benefits over up to 36 months.
Finerenone produced an early, sustained SBP reduction (overall placebo-adjusted mean: −3.1 mmHg; 95% CI, −3.6 to −2.6; P<.001), consistent across all baseline SBP categories. Cardiovascular death and total HF events were reduced irrespective of baseline SBP or DBP (P for interaction .96 and .83, respectively), and causal mediation analysis showed only ~7.4% of finerenone's benefit was mediated by SBP change (95% CI, −0.7 to 27.0).
- No 24-hour ambulatory BP monitoring, limiting BP characterization. - Exclusion of patients with symptomatic hypotension or uncontrolled SBP ≥160 mmHg (or ≥180 mmHg) may limit generalizability to extreme BP ranges. - Industry-sponsored trial (Bayer AG) with multiple author conflicts of interest.
Finerenone lowers BP modestly but its cardiovascular benefit in HFmrEF/HFpEF is not driven by BP reduction — clinicians can use it across a broad baseline BP range without concern that only hypertensive patients benefit. The ~1.6–2.0× higher odds of SBP <100 mmHg events with finerenone vs placebo were consistent across BP subgroups, so monitoring for hypotension remains relevant regardless of baseline BP.
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