Introduction: Finerenone is a non-steroidal mineralocorticoid receptor antagonist (MRA) approved for patients with chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM), with proven cardiovascular and renal benefits demonstrated in the FIDELIO-DKD and FIGARO-DKD trials. More recently, the FINEARTS-HF study evaluated its role in patients with heart failure with preserved ejection fraction (HFpEF), showing favourable effects in selected subgroups. However, hyperkalaemia remains a common limiting factor for the use of MRAs, especially in patients with multiple comorbidities.
Case presentation: We report the case of a 72-year-old man with a medical history of arterial hypertension and T2DM, admitted for decompensated heart failure with moderately reduced left ventricular ejection fraction. The patient was also diagnosed with severe aortic stenosis and two-vessel coronary artery disease, requiring surgical valve replacement and coronary artery bypass grafting. Upon admission, mild hyperkalaemia was detected, prompting temporary discontinuation of finerenone. Serum potassium levels normalised rapidly. After clinical stabilisation and surgical treatment, finerenone was reintroduced at discharge with close monitoring of renal function and electrolytes.
Discussion: This case highlights the practical challenges in optimising heart failure pharmacotherapy, particularly the management of hyperkalaemia associated with MRAs. Clinical trial data suggest that hyperkalaemia related to finerenone is generally mild and manageable. As observed in the FIDELITY pooled analysis and FINEARTS-HF trial, careful patient selection and laboratory surveillance can mitigate risks. Our case supports the idea that temporary withdrawal followed by reintroduction under supervision may allow continued use of finerenone in patients at risk of hyperkalaemia, ensuring they benefit from its cardiovascular protection.
Conclusion: Mild hyperkalaemia should not be regarded as an absolute contraindication to finerenone therapy. Individualised monitoring and dose adjustment strategies enable the safe use of MRAs in complex patients, allowing clinicians to harness their full therapeutic potential.