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ACC.21 Late Breaker: Finerenone and New-Onset Atrial Fibrillation or Flutter in Patients with Chronic Kidney Disease and Type 2 Diabetes

September 01, 2021.
Gerasimos Filippatos, MD, Athens, Greece
Dhanunjaya "DJ" Lakkireddy, MBBS, FACC, Overland Park, KS

Educational Objectives


After completing the activity, the clinician will be better able to discuss the potential role for finerenone in the treatment of patients at risk for atrial fibrillation.

Summary


ACC.21 Late Breaker: Finerenone and New-Onset Atrial Fibrillation or Flutter in Patients with Chronic Kidney Disease and Type 2 Diabetes

Correspondent: Anthony J. Mazzella, MD, Cary, NC

Take-home Messages:

  • Since chronic kidney disease (CKD) and type 2 diabetes can cause structural or electrical cardiac remodeling, patients with these conditions are at increased risk of developing atrial fibrillation (AF) and stroke.
  • The use of finerenone, a nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), has been associated with reductions in structural changes to the heart that lead to the development of AF.
  • Other MRAs have been studied in patients with AF and heart failure. In the EMPHASIS-HF TRIAL, eplerenone was reported to reduce the incidence of new-onset AF in patients with symptomatic heart failure with reduced ejection fraction (HFrEF). In the TOPCAT trial, spironolactone did not reduce the risk for either new-onset AF or AF recurrence in patients with symptomatic heart failure with preserved ejection fraction (HFpEF).
  • The FIDELIO-DKD study was a phase III trial designed to evaluate the effect of finerenone on kidney and cardiovascular outcomes in patients with CKD and type 2 diabetes. Approximately 5,700 patients with CKD and type 2 diabetes were randomized to finerenone or placebo. Patients had an estimated glomerular filtration rate (eGFR) of 25 to 75 mL/min per 1.73 m2 and were on optimized angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy. The trial excluded patients with HFrEF because HFrEF patients do not have indications for MRA therapy.
  • The composite kidney end point included kidney failure, sustained ≥40% decrease in eGFR from baseline over at least 4 weeks, or renal death. The composite cardiovascular outcome included cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure. The overall incidences of the kidney and cardiovascular outcomes were significantly lower with finerenone than with placebo.
  • Investigators found that the incidence of new-onset AF and atrial flutter were significantly lower in patients treated with finerenone, compared with those who received placebo. The effect was seen from 6 months and was sustained throughout the trial. The cardioprotective effect of finerenone did not differ significantly between patients with and without preexisting AF.
  • One key limitation of the study was the low number of new-onset AF or flutter events, and it is likely that several cases of asymptomatic AF were missed as patients in the study were monitored only periodically with electrocardiography.
  • Treatment of patients with CKD and type 2 diabetes can be challenging because of increased risk for blood clots and bleeding.
  • The FIDELIO-DKD trial suggests that finerenone may be effective in preventing the development of AF in patients with CKD and type 2 diabetes. The beneficial effects of finerenone on the kidney and cardiac outcomes are equally effective in patients with or without preexisting AF. Finerenone has the potential to reduce the burden of AF in these patients. Further studies are needed to support or clarify these findings.
  • The effect of finerenone on new-onset AF in patients with HFpEF is currently being studied in the ongoing FINEARTS-HF trial. Data from the FIGARO-DKD study, a trial looking at the long-term effect of finerenone on heart and kidney outcomes in patients with less severe chronic kidney disease and type 2 diabetes, are expected to be presented later this year.
  • Finerenone is a novel and investigational MRA that may provide a new treatment option for the prevention of AF in certain patient populations, but is currently not approved for AF prevention.

References

1. Bakris GL, Agarwal R, Anker SD, et al. Effect of finerenone on chronic kidney disease outcomes in type 2 diabetes. N Engl J Med. 2020;383(23):2219-2229. doi:10.1056/NEJMoa2025845

2. Filippatos G, Anker SD, Agarwal R, et al. Finerenone and cardiovascular outcomes in patients with chronic kidney disease and type 2 diabetes. Circulation. 2021;143(6):540-552. doi:10.1161/CIRCULATIONAHA.120.051898

3. Neefs J, van den Berg NWE, Krul SPJ, Boekholdt SM, de Groot JR. Effect of spironolactone on atrial fibrillation in patients with heart failure with preserved ejection fraction: post-hoc analysis of the randomized, placebo-controlled TOPCAT trial. Am J Cardiovasc Drugs. 2020;20(1):73-80. doi:10.1007/s40256-019-00353-5

4. Swedberg K, Zannad F, McMurray JJ, et al. Eplerenone and atrial fibrillation in mild systolic heart failure: results from the EMPHASIS-HF (Eplerenone in Mild Patients Hospitalization And SurvIval Study in Heart Failure) study. J Am Coll Cardiol. 2012;59(18):1598-1603. doi:10.1016/j.jacc.2011.11.063

Readings


Disclosures


Gerasimos Filippatos: Other: Amgen Inc., Bayer, Boehringer Ingelheim Pharmaceuticals, Inc., MEDTRONIC, Novartis, Servier, Vifor Pharma.

Dhanunjaya “DJ” Lakkireddy: This author has nothing to disclose.

Acknowledgements


CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AC530902

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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