Practical Implementation of Steroidal and Nonsteroidal Mineralocorticoid Receptor Antagonists in the Management of Heart Failure.

Mineralocorticoid receptor antagonists (MRAs) are a well-established treatment option for the management of heart failure (HF) with reduced ejection fraction. However, high-quality evidence for the effect of MRAs in the treatment of heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) has been limited until recent years. The nonsteroidal MRA finerenone has demonstrated efficacy in this population and was approved for treatment in July 2025 by the U.S. Food and Drug Administration. A call to action is needed to increase the use of guideline-directed medical therapy in HFmrEF/HFpEF with simultaneous or rapid sequence initiation of a combination therapy. This review provides an overview of MRAs approved for use in HF management, with particular focus on HFmrEF/HFpEF. Guideline recommendations and HF label indications are discussed, highlighting practical considerations for the safe use of MRAs in clinical practice. In addition, the therapeutic management of patients with HFmrEF/HFpEF and concomitant cardiovascular, kidney, and metabolic diseases is considered.