Clara I. Saldarriaga-Giraldo, Servicio de Cardiología, Clínica Cardio VID, Medellín, Colombia
Paula A. Cárdenas-Marín, Unidad de Insuficiencia Cardíaca, Clínica Universitaria Colombia Grupo Keralty, Bogotá, Colombia
Oscar Aguirre-Zurita, Unidad de Insuficiencia Cardíaca e Hipertensión Pulmonar, Instituto Nacional Cardiovascular INCOR, Lima, Perú
Carlos A. Arias-Barrera, Unidad de Insuficiencia Cardíaca, Clínica Universitaria Colombia Grupo Keralty, Bogotá, Colombia
Sergio Fuentes, Unidad de Falla Cardíaca, Clínica Los Nogales, Bogotá, Colombia
Pablo González-Velásquez, Departamento de Cardiología, Hospital General San Juan de Dios, Guatemala, Guatemala
Luis Guerrero-Cepeda, Departamento de Cardiología, Hospital de Especialidades Eugenio Espejo, Quito, Ecuador
Álvaro Herrera-Escandón, Programa de Falla Cardíaca y Trasplante Cardíaco, Clínica Imbanaco, Cali, Colombia
Erika Martínez-Carreño, Departamento de Cardiología, Clínica Iberoamérica, Barranquilla, Colombia
Fernán Mendoza, Departamento de Cardiología Clínica, Fundación Clínica Shaio, Bogotá, Colombia
Paola Morejón-Barragán, Departamento de Cardiología, Clínica Guayaquil, Guayaquil, Ecuador
Gustavo Ortega-Ramírez, Departamento de Cardiología, Clínica General del Norte, Barranquilla, Colombia
Jhon A. Ramírez-Martínez, Unidad de Falla Cardíaca, La Cardio, Bogotá, Colombia
Juliana Salas-Segura, Programa de Insuficiencia Cardíaca, Hospital Clínica Bíblica, San José, Costa Rica
Harry Soto-Alvarado, Departamento de Cardiología, Hospital General San Juan de Dios, Guatemala, Guatemala
Alex A. Rivera-Toquica, Cardiología SAS-Universidad Tecnológica de Pereira, Pereira, Colombia
Juan E. Gómez-Mesa, Servicio de Cardiología, Fundación Valle del Lili, Cali; Facultad de Ciencias de la Salud, Universidad Icesi, Cali; Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali; Sociedad Colombiana de Cardiología y Cirugía Cardiovascular, Bogotá; Colombia
Heart failure (HF) is a clinical syndrome with high prevalence and mortality, classified according to left ventricular ejection fraction (LVEF) as HF with reduced (HFrEF), mildly reduced (HFmrEF), or preserved (HFpEF) ejection fraction. Activation of the renin-angiotensin-aldosterone system promotes inflammation, fibrosis, and myocardial remodeling that can be mitigated using mineralocorticoid receptor antagonists (MRAs). These are divided into steroidal (spironolactone and eplerenone) and nonsteroidal (finerenone) medications, with different selectivity and safety. This article describes the available evidence on the use of MRAs across the entire LVEF spectrum. A narrative review was performed using a search in PubMed, Embase, Scopus, and Cochrane Library between 1999 and 2025. In HFrEF, steroidal MRAs have demonstrated tangible benefits. The RALES study showed a 30% reduction in total mortality with spironolactone, while EPHESUS and EMPHASIS-HF confirmed that eplerenone reduces mortality and hospitalizations for HF. However, these drugs increase the risk of hyperkalemia, especially in patients with chronic kidney disease. In HFmrEF and HFpEF, the evidence for spironolactone has been mixed; although TOPCAT did not significantly reduce the primary outcome, it did reduce hospitalizations for HF. FINEARTS-HF indicated that finerenone significantly reduces HF worsening in patients with LVEF ≥ 40%. Mineralocorticoid receptor antagonists continue to be essential for HF, and finerenone expands treatment options for HFmrEF and HFpEF, with clinical efficacy and a favorable safety profile.
Keywords: Heart failure. Mineralocorticoid receptor antagonists. Spironolactone. Eplerenone. Finerenone. Mortality. Hospitalization.
