MRAs in HFpEF & HFmrEF: A Clinical Debate

Are mineralocorticoid receptor antagonists (MRAs) ready for prime time in HFpEF and HFmrEF?  In this special debate-format episode of the Heart Failure Beat, two leading heart failure pharmacists, Stormi Gale, PharmD, BCCP, FHFSA and Robert L Page II, PharmD, MSPH, FHFSA, go head-to-head on steroidal vs non-steroidal MRAs.  From RALES and TOPCAT to FINEARTS-HF, they unpack the evidence, guideline implications, cost-effectiveness, CKM considerations, and real-world barriers to access. Is finerenone the “new pillar” in HFpEF? Or does spironolactone remain the practical, evidence-based choice? The conversation also explores phenotyping challenges in HF trials and whether combining SGLT2 inhibitors with MRAs can attenuate hyperkalemia risk.  If you care about precision medicine, cardiorenal overlap, or optimizing GDMT in complex patients, this debate is for you.