In a propensity score-matched real-world analysis of 1,012 high-risk post-AMI patients (mean age 69, ~84% with type 2 diabetes, ~80% with CKD), initiating finerenone within six months of a heart attack was associated with a 35.6% lower risk of the composite endpoint of mortality and heart failure (HR 0.644), a 42.7% lower risk of progression to end-stage renal disease (HR 0.573), and a 39.8% lower reduction in all-cause hospitalization over two years — with no significant increase in hyperkalemia, hyponatremia, or hypotension.
Finerenone, a non-steroidal mineralocorticoid receptor antagonist, has already reshaped cardiorenal medicine through the FIDELIO-DKD and FIGARO-DKD trials, and more recently the FINEARTS-HF trial in heart failure with preserved ejection fraction. This analysis attempts to extend its clinical utility into the acute post-MI window — a setting where older steroidal MRAs like spironolactone carry significant hyperkalemia risk and limited tolerability. The effect sizes here are striking, but several caveats demand caution. The cohort is small (506 per group), retrospective, and drawn from a federated claims-adjacent network where residual confounding is difficult to eliminate despite propensity matching. The extremely high prevalence of CKD and diabetes suggests extreme selection bias — this phenotype may not generalize broadly. Critically, this is a preprint posted on medRxiv and has not yet undergone peer review; findings could change materially. Prospective randomized trials are essential before clinical practice should shift.
