Don't Miss a Beat: MRA Updates at ACC 2026 Scientific Sessions

Welcome back to Don't Miss a Beat!

Few subspecialties in cardiovascular medicine have welcomed the same abundance of new data and clinical trials as heart failure specialists, particularly as it relates to heart failure with preserved ejection fraction (HFpEF) or mildly reduced ejection fraction (HFmrEF).

Against that backdrop, the mineralocorticoid receptor antagonist (MRA) class has emerged as a focal point of ongoing debate. Current US heart failure guidelines assign MRAs a Class IIb recommendation in HFpEF, which is a designation reflecting uncertainty shaped in large part by the contested TOPCAT trial, where a post-hoc analysis of the Americas subpopulation suggested benefit, even as the full trial failed its primary endpoint.

SPIRIT-HF, presented at the American College of Cardiology's Annual Scientific Session (ACC.26), now adds a prospective null result to that record, while finerenone continues accumulating phase 3 evidence across diabetic and non-diabetic chronic kidney disease populations — most recently through the FINE-ONE and FIND-CKD trials announced ahead of ACC.26.

In this episode of Don’t Miss a Beat, hosts Muthiah Vaduganathan, MD, MPH, a cardiologist and codirector of the Center for Cardiometabolic Implementation Science at Brigham and Women’s Hospital, and Stephen Greene, MD, an advanced heart failure specialist at Duke University School of Medicine, break down the latest updates and news related to mineralocorticoid receptor agonists, including a deep dive into SPIRIT-HF and topline announcements from finerenone’s phase 3 clinical trial program.

SPIRIT-HF

On March 29, 2026, investigators presented results from the SPIRIT-HF trial at ACC.26 showing spironolactone did not significantly reduce the composite of heart failure hospitalization and cardiovascular death compared with placebo in patients with HFpEF or HFmrEF.

Based on the randomized, placebo-controlled trial of 730 patients across 56 European centers, event rates at 24 months were 12.7 versus 10.8 per 100 patient-years in the spironolactone and placebo groups, respectively, with no significant difference observed across prespecified subgroups.

Secondary endpoints revealed significantly greater rates of total hospitalizations, hypotension, renal events, and hyperkalemia in the spironolactone arm, and more than half of participants assigned to the drug discontinued treatment before trial completion, largely attributable to COVID-19 pandemic disruptions.

A pooled meta-analysis incorporating TOPCAT Americas data similarly showed no significant benefit, leaving the role of aldosterone blockade in HFpEF and HFmrEF unresolved pending additional registry data.

FINE-ONE

On November 6, 2025, Bayer announced positive phase 3 results from the FINE-ONE trial evaluating finerenone in adults with type 1 diabetes and chronic kidney disease. Based on the randomized, double-blind, placebo-controlled trial in 242 participants, finerenone added to standard of care demonstrated a 25% relative reduction in urine albumin-to-creatinine ratio from baseline over 6 months compared with placebo (95% CI, 0.65–0.87; P = .0001).

FIND-CKD

On March 16, 2026, Bayer announced positive phase 3 results from the FIND-CKD trial evaluating finerenone versus placebo added to standard of care in adults with non-diabetic chronic kidney disease. Based on the randomized phase 3 trial, finerenone demonstrated a statistically significant improvement in eGFR slope, the mean annual rate of eGFR change from baseline to month 32, a validated surrogate endpoint for kidney failure risk.

Finerenone has now shown kidney-protective benefits across 5 completed phase 3 studies spanning diabetic and non-diabetic CKD populations. In their March 16 announcement, Bayer disclosed plans to submit the FIND-CKD data to health authorities to pursue a label extension to non-diabetic CKD.

Relevant disclosures for Vaduganathan include Amgen, AstraZeneca, Bayer AG, Boehringer Ingelheim Pharmaceuticals, Cytokinetics, Lexicon, and others. Relevant disclosures for Greene include Amgen, AstraZeneca, Bayer Healthcare Pharmaceuticals, Boehringer Ingelheim Pharmaceuticals, Cytokinetics, and others.

References:

1. American College of Cardiology. Study Finds No Significant Benefit of Spironolactone in HFpEF or HFmrEF - American College of Cardiology. American College of Cardiology. Published March 29, 2026. Accessed March 31, 2026. https://www.acc.org/About-ACC/Press-Releases/2026/03/29/14/57/Study-Finds-No-Significant-Benefit-of-Spironolactone-in-HFpEF-or-HFmrEF

2. Bayer. Finerenone showed statistically significant reduction of UACR in adults with chronic kidney disease associated with type 1 diabetes. Bayer. Published November 6, 2025. Accessed November 6, 2025. https://www.bayer.com/media/en-us/finerenone-showed-statistically-significant-reduction-of-uacr-in-adults-with-chronic-kidney-disease-associated-with-type-1-diabetes/

3. Bayer. KERENDIA® (finerenone) Meets Primary Endpoint in Investigational Phase III FIND-CKD Study in Patients with Non-Diabetic Chronic Kidney Disease. Bayer.com. Published March 16, 2026. Accessed March 31, 2026. https://www.bayer.com/en/us/news-stories/kerendiar-meets-primary-endpoint