Cardiorenal Outcomes with Finerenone in Patients Post-Acute Myocardial Infarction: Insights from a Global Federated Network

Background: Finerenone, a non-steroidal mineralocorticoid receptor antagonist (nsMRA), improves cardiorenal outcomes in chronic kidney disease, type 2 diabetes, and heart failure. However, its clinical efficacy and safety when initiated early after acute myocardial infarction (AMI) remain unknown. Methods: This retrospective cohort study utilized the TriNetX global federated network to identify adult patients with AMI who initiated finerenone within 6 months of the index event. These were compared to a propensity score-matched control group of AMI survivors who did not receive finerenone. Results: After 1:1 propensity score matching, 1,012 patients were included (506 per group; mean age 69 years). The cohort represented a high-risk phenotype with a high prevalence of type 2 diabetes (~84%) and CKD (~80%). Over a 2-year follow-up, finerenone treatment was associated with a lower risk of the composite endpoint of mortality and heart failure (HR 0.644; 95% CI 0.495?0.837; P < 0.001). Notably, finerenone was also associated with a lower risk of progression to ESRD or CKD stage 5 (HR 0.573; 95% CI 0.387?0.851; P = 0.005) and all-cause hospitalization (HR 0.602; 95% CI 0.482?0.751; P < 0.001). There was no significant difference in the risk of adverse events, including hyperkalemia, hyponatremia, and syncope or hypotension between groups. Conclusion: In this real-world study of high-risk post-AMI patients, early initiation of finerenone was associated with lower risks of composite cardiovascular events, all-cause mortality, and renal disease progression, without a significant increase in adverse events. These findings warrant validation in prospective randomized controlled trials.