Abstract / Summary
Abstract Background Heart failure with preserved ejection fraction (HFpEF) disproportionately affects older adults, in whom dementia and cognitive decline are frequent but underrecognized. Steroidal mineralocorticoid receptor antagonists (MRAs) have been linked to lower dementia risk. Whether this extends to finerenone is unknown. Methods This retrospective TriNetX cohort study identified adults aged ≥ 65 with a first HFpEF diagnosis (July 9, 2021–September 14, 2026). The primary outcome was six-month incidence of dementia or cognitive decline; the secondary was a composite adverse renal outcome. Results Each matched cohort included 1,660 patients. Dementia or cognitive decline occurred in 1% of the finerenone group versus 1.4% of controls (HR 0.9, 95%CI 0.46─1.60). The composite renal outcome was significantly lower with finerenone (11.1% vs 20.3%; HR 0.6, 95%CI 0.47─0.67). Conclusion In older adults with HFpEF, finerenone conferred renal benefit without a detectable short-term cognitive signal. Longer follow-up with standardized cognitive assessment is needed before excluding neuroprotection.