Are mineralocorticoid receptor antagonists (MRAs) ready for prime time in HFpEF and HFmrEF?
In this special debate-format episode of the Heart Failure Beat, two leading heart failure pharmacists, Stormi Gale, PharmD, BCCP, FHFSA and Robert L. Page II, PharmD, MSPH, FHFSA, go head-to-head on steroidal vs non-steroidal MRAs.
From RALES and TOPCAT to FINEARTS-HF, they unpack the evidence, guideline implications, cost-effectiveness, CKM considerations, and real-world barriers to access. Is finerenone the “new pillar” in HFpEF? Or does spironolactone remain the practical, evidence-based choice? The conversation also explores phenotyping challenges in HF trials and whether combining SGLT2 inhibitors with MRAs can attenuate hyperkalemia risk.
If you care about precision medicine, cardiorenal overlap, or optimizing GDMT in complex patients, this debate is for you.
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References, Links and Disclosures
Stormi Gale, PharmD, BCCP, FHFSA: Panel speaker, American Regent
Agarwal R, Green JB, Heerspink HJL, Mann JFE, McGill JB, Mottl AK, Rosenstock J, Rossing P, Vaduganathan M, Brinker M, Edfors R, Li N, Scheerer MF, Scott C, Nangaku M; CONFIDENCE Investigators. Finerenone with Empagliflozin in Chronic Kidney Disease and Type 2 Diabetes. N Engl J Med. 2025 Aug 7;393(6):533-543. doi: 10.1056/NEJMoa2410659. Epub 2025 Jun 5. PMID: 40470996.
Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J, Wittes J. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999 Sep 2;341(10):709-17. doi: 10.1056/NEJM199909023411001. PMID: 10471456.
Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H, Vincent J, Pocock SJ, Pitt B; EMPHASIS-HF Study Group. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 2011 Jan 6;364(1):11-21. doi: 10.1056/NEJMoa1009492. Epub 2010 Nov 14. PMID: 21073363.
Solomon SD, McMurray JJV, Vaduganathan M, Claggett B, Jhund PS, Desai AS, Henderson AD, Lam CSP, Pitt B, Senni M, Shah SJ, Voors AA, Zannad F, Abidin IZ, Alcocer-Gamba MA, Atherton JJ, Bauersachs J, Chang-Sheng M, Chiang CE, Chioncel O, Chopra V, Comin-Colet J, Filippatos G, Fonseca C, Gajos G, Goland S, Goncalvesova E, Kang S, Katova T, Kosiborod MN, Latkovskis G, Lee AP, Linssen GCM, Llamas-Esperón G, Mareev V, Martinez FA, Melenovský V, Merkely B, Nodari S, Petrie MC, Saldarriaga CI, Saraiva JFK, Sato N, Schou M, Sharma K, Troughton R, Udell JA, Ukkonen H, Vardeny O, Verma S, von Lewinski D, Voronkov L, Yilmaz MB, Zieroth S, Lay-Flurrie J, van Gameren I, Amarante F, Kolkhof P, Viswanathan P; FINEARTS-HF Committees and Investigators. Finerenone in Heart Failure with Mildly Reduced or Preserved Ejection Fraction. N Engl J Med. 2024 Oct 24;391(16):1475-1485. doi: 10.1056/NEJMoa2407107. Epub 2024 Sep 1. PMID: 39225278.
Pitt B, Kober L, Ponikowski P, Gheorghiade M, Filippatos G, Krum H, Nowack C, Kolkhof P, Kim SY, Zannad F. Safety and tolerability of the novel non-steroidal mineralocorticoid receptor antagonist BAY 94-8862 in patients with chronic heart failure and mild or moderate chronic kidney disease: a randomized, double-blind trial. Eur Heart J. 2013 Aug;34(31):2453-63. doi: 10.1093/eurheartj/eht187. Epub 2013 May 27. PMID: 23713082; PMCID: PMC3743070.
Disclaimer
The opinions and perspectives expressed in this episode are those of the individual guests and hosts and do not necessarily reflect the official views of the Heart Failure Society of America (HFSA). This discussion is intended for educational purposes only and does not constitute medical advice or an endorsement of any specific pharmaceutical product or therapy. HFSA does not endorse one medication over another. Patients should consult their healthcare professionals for individualized evaluation and treatment decisions.