Finerenone after FINEARTS-HF: evidence boundaries and implementation in heart failure with LVEF ≥40.

FINEARTS-HF moved finerenone from cardiorenal biological plausibility to randomized outcome evidence for selected adults with symptomatic heart failure (HF) and left ventricular ejection fraction (LVEF) ≥40%. Finerenone reduced the prespecified composite of cardiovascular death and total worsening HF events, with benefit driven mainly by fewer worsening HF events; cardiovascular death as an individual endpoint was not significantly reduced. This focused narrative Review defines the evidence boundaries after FINEARTS-HF and translates them into clinical implementation for cardiovascular-kidney-metabolic (CKM)-burdened HF with LVEF ≥40%. CKM features are used as a practical framework for risk organization, multimorbidity assessment, competing symptom mechanisms, and monitoring intensity, not as diagnostic criteria, eligibility criteria, or validated predictors of relative response. Safe use requires confirmed symptomatic HF, exclusion of mimickers, confirmation of the local prescribing information, baseline potassium and eGFR assessment, HF-specific dosing, interaction review, laboratory reassessment around 4 weeks after initiation and dose changes, and reassessment during acute illness or unstable renal function. Finerenone should complement SGLT2 inhibitors, decongestion, obesity-directed therapy when indicated, atrial fibrillation care, blood-pressure control, exercise, and nutrition. Future studies should quantify absolute benefit across CKM risk, test UACR, biomarker, and imaging mediation, define combination and sequencing strategies, compare safety with steroidal mineralocorticoid receptor antagonists, and evaluate real-world implementation.