Half of England’s heart failure patients have spent decades watching the other half get all the drugs. That’s the context for what NICE did this week.
On 16 July, the institute published final draft guidance recommending finerenone for adults with chronic heart failure with preserved or mildly reduced ejection fraction. NICE estimates up to 280,000 people in England could be eligible a large number by any standard, and a striking one for a condition that has had so little to offer.
The split matters. Of the roughly 635,000 people in England living with heart failure, about half have the preserved or mildly reduced form. In the reduced ejection fraction version, the heart’s pumping is visibly weakened, and clinicians have built up a deep armoury against it over thirty years: ACE inhibitors, beta blockers, MRAs, ARNIs, more recently SGLT2 inhibitors. The preserved variety is different. Here, the problem lies in the filling phase: the left side of the heart doesn’t fill properly with blood during diastole, so it can’t pump enough to meet the body’s needs. The drop in output is smaller than in the reduced form, which for years made it look like the milder problem. It isn’t. And until SGLT2 inhibitors arrived, almost nothing had been shown to change its course.
So a second effective option is a bigger deal than the phrasing of NICE’s announcement suggests.
Finerenone is a mineralocorticoid receptor antagonist, the same class as spironolactone, a drug that has been in cardiology cupboards since the 1960s. The difference is structural. Finerenone is a non-steroidal, selective MRA, whereas the older drugs are steroidal. That distinction isn’t academic: steroidal MRAs also bind androgen and progesterone receptors, which is why spironolactone can bring breast tenderness, gynaecomastia and sexual dysfunction along with its benefits, and why a fair number of patients stop taking it. NICE’s own framing is characteristically dry because finerenone is nonsteroidal; it may be usable by more people. That’s the practical translation of a lot of abandoned prescriptions.
The drug is Bayer’s, sold as Kerendia, and it isn’t new. The FDA first approved it in July 2021 to cut the risk of kidney decline, end-stage kidney disease, cardiovascular death, non-fatal heart attack, and heart failure hospitalisation in adults with chronic kidney disease linked to type 2 diabetes. The heart failure indication came later, off the back of a trial called FINEARTS-HF. It enrolled 6,016 patients with NYHA class II to IV heart failure and an ejection fraction of 40% or more, all on diuretics for at least 30 days beforehand, and showed a 16% relative reduction in the composite of cardiovascular death and total heart failure events when added to standard care. The results went to the ESC Congress in 2024 and into the New England Journal of Medicine. The FDA cleared the new indication in July 2025.
The comorbidity picture is what makes this population hard to treat, and it’s also where the kidney heritage becomes relevant. Many people with chronic heart failure are simultaneously managing chronic kidney disease, diabetes, and high blood pressure. A drug already carrying evidence in the kidney-diabetes overlap is landing in a group where that overlap is the norm rather than the exception. Worth noting: finerenone still carries a hyperkalaemia warning. Nonsteroidal doesn’t mean consequence-free, and potassium monitoring doesn’t go away.
NICE’s argument for value leans on hospital beds. Heart failure drove around 100,000 hospitalisations in England in 2023 to 2024, making it one of the leading causes of avoidable admissions, and the symptoms behind them- breathlessness, fatigue, swollen ankles- are the kind that erode independence long before they put someone on a ward.
Helen Knight, NICE’s director of medicines evaluation, made the fiscal case explicitly. Beyond helping people live well for longer, she argued the drug could save the NHS money and free up capacity by keeping people out of emergency care.
This is final draft guidance rather than the finished article. NICE expects to publish final guidance in August 2026.