Nonsteroidal Mineralocorticoid Receptor Antagonists and Cardiovascular Events in Type 2 Diabetes: A Retrospective Study.

Aims: Nonsteroidal mineralocorticoid receptor antagonists such as finerenone mitigate cardiorenal risks in patients with type 2 diabetes mellitus (T2DM). Real-world evidence comparing finerenone with spironolactone and eplerenone remains limited. This study aimed to evaluate the cardiovascular outcomes in T2DM patients treated with finerenone versus spironolactone or eplerenone using real-world data.

Methods and results: A retrospective cohort analysis was conducted using the TriNetX US Collaborative Network database. Adult patients with T2DM who were newly prescribed finerenone, spironolactone, or eplerenone were included (2021-2024). One-to-one propensity score matching was applied to eligible participants, resulting in 2,957 finerenone users matching with spironolactone users and 1,603 finerenone users matching with eplerenone users. Cardiovascular outcomes, including major adverse cardiovascular events (MACE), heart failure, and mortality, were assessed over 24 months of follow-up. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated using Cox regression models. Finerenone users had significantly lower rates of MACE compared with spironolactone users (HR: 0.53, 95% CI: 0.43-0.66) and eplerenone (HR: 0.66, 95% CI: 0.50-0.87). Mortality was also reduced with finerenone versus spironolactone (HR: 0.45, 95% CI: 0.35-0.57) and eplerenone (HR: 0.56, 95% CI: 0.41-0.75). Heart failure events were fewer with finerenone than with spironolactone (HR: 0.70, 95% CI: 0.55-0.90) and eplerenone (HR: 0.70, 95% CI: 0.50-0.99). Differences in acute myocardial infarction and stroke rates were not statistically significant.

Conclusions: Finerenone demonstrated superior cardiovascular outcomes compared with spironolactone and eplerenone in patients with T2DM with significant reductions in MACE, mortality, and heart failure events.