Heart Failure Phenotype and 1-Year Outcomes Across Different Stages of Chronic Kidney Disease

Presenter: Maria Anguita Gamez

In patients with heart failure (HF), the prognostic impact of chronic kidney disease (CKD) may vary according to HF phenotype. A contemporary Spanish registry of 2,245 patients from 68 specialised HF units compared clinical characteristics, treatment and 1-year outcomes across heart failure with reduced ejection fraction (HFrEF), mildly reduced ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF), stratified by CKD stages 4–5 versus 1–3. CKD stages 4–5 were present in 9.9% of patients and were associated with lower use of angiotensin receptor-neprilysin inhibitors (ARNI), mineralocorticoid receptor antagonists (MRA), beta-blockers and sodium-glucose cotransporter-2 inhibitors (SGLT2i) among HFrEF and HFmrEF patients. In CKD stages 4–5, HFrEF was associated with the highest 1-year mortality and HF hospitalisation rates, followed by HFmrEF and HFpEF. In contrast, outcomes did not differ significantly by HF phenotype in CKD stages 1–3. The findings indicate that renal dysfunction modifies the relationship between HF phenotype and clinical outcomes, with differences becoming evident mainly in advanced CKD.

Balancing Cardiovascular Benefit and Safety of Intensive Blood Pressure Control Across Renal Risk: ESPRIT

Presenter: Shitian Li

Previous trials have shown that intensive blood pressure (BP) control can reduce cardiovascular events and mortality, but concerns remain about kidney-related adverse events, particularly with greater renal impairment. A post hoc analysis of ESPRIT evaluated whether the balance of benefit and risk varied across Kidney Disease: Improving Global Outcomes (KDIGO) risk classes. Among 11,196 high-cardiovascular-risk participants, 70.9% had low, 23.5% moderate and 5.6% high/very high KDIGO risk. Intensive BP control targeting systolic BP <120 mmHg provided similar relative protection against the composite cardiovascular outcome and cardiovascular mortality across KDIGO risk classes. However, patients with greater baseline KDIGO risk experienced progressively larger absolute reductions in these outcomes. Importantly, intensive treatment did not increase safety risks among participants with high KDIGO risk. The findings support using KDIGO risk classification to help individualise decisions on intensive BP control, particularly where the potential absolute benefit may be greater.

Effects of Empagliflozin on Skeletal Muscle Degradation in Patients with Heart Failure: A Prospective Observational Study

Presenter: T Nishikawa

Whether SGLT2 inhibitors influence skeletal muscle degradation in patients with heart failure remains insufficiently characterized, particularly in the context of older and frail populations. This prospective, single-centre observational study evaluated changes in urinary titin N-fragment (U-titin), a biomarker of skeletal muscle breakdown, over 6 months after initiating empagliflozin 10 mg once daily in 93 consecutive patients with stable heart failure enrolled between February 2023 and October 2024. Median age was 79 years (IQR 72–83), 40% were women, and baseline BMI was 22.8 kg/m² (IQR 19.8–26.2); 46% had HFpEF (LVEF 50%). Median U-titin increased numerically from 1.7 pmol/mg Cr (IQR 1.1–3.5) to 2.4 pmol/mg Cr (IQR 1.3–4.2), but the change was not significant (p=0.629). Nutritional indices, KCCQ-12 scores, BMI, and NT-proBNP improved significantly. HFpEF independently predicted a >50% U-titin increase (OR 3.31, 95% CI 1.23–9.52; p=0.017). Thus, empagliflozin was not associated with significant overall skeletal muscle degradation over 6 months, although patients with preserved ejection fraction may warrant further investigation. 

The DIALY-MRA Trial: A Randomised Comparison of Finerenone versus Spironolactone in Patients on Maintenance Dialysis – A 3-month Biomarker and Safety Study

Presenter: R Rascon Sabido

Patients with end-stage kidney disease (ESKD) receiving maintenance dialysis have high cardiovascular risk but have been systematically excluded from MRA trials, leaving uncertainty about the comparative role of finerenone and spironolactone in this population. This single-centre, randomised, open-label trial compared the two agents over 3 months in 276 patients on maintenance dialysis, including 221 (80%) receiving haemodialysis and 55 (20%) peritoneal dialysis. Patients were randomised 2:1 to spironolactone 25 mg daily (n=184) or finerenone 10 mg daily, titrated to 20 mg if tolerated (n=92). At 3 months, the composite of cardiovascular death or heart failure hospitalisation occurred in 9.8% versus 7.6% of patients, respectively (HR: 0.78; 95% CI 0.61–0.99; p=0.045), with lower heart failure hospitalisation (4.3% vs. 6.5%; p=0.048). NT-proBNP declined more with finerenone, with a median change of -28% (IQR -42 to -15) versus -19% (IQR -32 to -8); p=0.03. Hyperkalaemia occurred in 8.7% versus 14.1% (p=0.046), gynaecomastia in 1.1% versus 7.6% (p<0.001), and adverse-event-related discontinuation in 4.3% versus 9.2% (p=0.046). 

ESC Congress 2026, 28 - 31 Aug, Munich, Germany