Finerenone and new-onset diabetes in heart failure: a prespecified analysis of the FINEARTS-HF trial.

Summary

In a prespecified analysis of FINEARTS-HF, finerenone reduced new-onset diabetes by 24% versus placebo in HFpEF/HFmrEF patients without diabetes (HR 0.76; median follow-up 31.3 months). Findings were consistent in competing risk and multiple sensitivity analyses, underscoring a metabolic benefit in addition to heart failure indications.

Key Findings

• New-onset diabetes incidence was 3.0 vs 3.9 events per 100 person-years for finerenone vs placebo; HR 0.76 (95% CI 0.59–0.97).
• Competing risk analysis (death as competing event) confirmed benefit: subdistribution HR 0.75 (95% CI 0.59–0.96).
• Effects were consistent across sensitivity analyses, including definitions incorporating SGLT2i initiation or HbA1c-restricted criteria.
• Population: 3222 participants without diabetes at baseline from a 6001-patient RCT; median follow-up 31.3 months.

Clinical Implications

In HFpEF/HFmrEF without diabetes, finerenone may be favored when metabolic risk is a concern, offering potential diabetes prevention alongside standard HF management; monitor potassium and renal function per MR antagonist best practices.

Limitations

• Diabetes incidence was not the primary endpoint of the parent trial
• Generalizability limited to HFpEF/HFmrEF; background SGLT2i use and glycemic surveillance may vary by region/time

Future Directions

Prospective trials powered for diabetes prevention endpoints in HF populations and mechanistic studies on MR pathway effects on beta-cell/insulin sensitivity.