Individuals with heart failure (HF) are at a higher risk of developing diabetes, which can worsen HF symptoms, kidney function, and overall survival. All three types of HF, reduced ejection fraction (HFrEF), mid-range ejection fraction (HFmrEF), and preserved ejection fraction (HFpEF)—are linked to an increased risk of diabetes. HFmrEF and HFpEF, in particular, may have a stronger association due to obesity.

      The FINEARTS-HF trial, a randomized, double-blind, placebo-controlled study, examined the safety and effectiveness of finerenone in individuals with HFmrEF or HFpEF. Since heart failure activates the renin-angiotensin-aldosterone system, leading to insulin resistance, researchers were interested in whether mineralocorticoid receptor antagonists (MRAs) like finerenone could reduce diabetes risk. The study enrolled 6001 patients with HFmrEF or HFpEF to evaluate finerenone’s impact on new-onset diabetes, heart failure outcomes, and quality of life.

      Participants were randomly assigned to receive finerenone or a placebo if they were at least 40 years old, had a left ventricular ejection fraction (LVEF) of 40% or higher, and had been on diuretics for at least 30 days. Key exclusion criteria included an estimated glomerular filtration rate (eGFR) below 25 mL/min/1.73 m² or potassium levels above 5.0 mmol/L. The study tracked new-onset diabetes, defined as an HbA1c of 6.5% or higher or the initiation of glucose-lowering medications.

      Of the 6001 participants, 1243 (20.7%) had normoglycemia, 1979 (30.0%) had prediabetes, and 2779 (46.3%) had diabetes at baseline. Among the 3222 participants without diabetes, 61.4% had prediabetes. During a median follow-up of 31.3 months, 262 participants developed diabetes, with 176 meeting the HbA1c threshold and 45% beginning glucose-lowering treatment such as SGLT2 inhibitors.

      Finerenone was associated with a lower risk of new-onset diabetes compared to placebo. The hazard ratio of 0.76 suggested a 24% relative risk reduction, with diabetes developing in 7.2% of those on finerenone compared to 9.1% in the placebo group. These findings remained consistent across all sensitivity analyses and subgroups, including participants with normoglycemia and prediabetes at baseline.