Blood Pressure-Lowering Effects of Finerenone: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

Background: Optimal blood pressure (BP) control remains elusive for millions of patients worldwide, often leading to resistant or secondary hypertension. Overactivation of the mineralocorticoid receptor (MR) drives this systemic pathology. While steroidal mineralocorticoid receptor antagonists (MRAs) are effective, their clinical utility is limited by poor cross-selectivity and risk of hyperkalemia. Finerenone, a novel non-steroidal MRA, offers high selectivity and potent target-organ protection, but a comprehensive pooling of its direct impact on BP is still needed. Methods: Following the PRISMA guidelines, a systematic search was conducted across PubMed, Embase, and ClinicalTrials.gov up to August 2026 for randomized controlled trials (RCTs) comparing finerenone versus placebo and reporting BP outcomes. The primary outcome was office systolic blood pressure (SBP). Results: Six RCTs involving 19,609 patients were included. Finerenone demonstrated a statistically significant but modest reduction in both office SBP (LSM difference: −2.83 mmHg; 95% CI: −3.15 to −2.51; p < 0.001) and office diastolic blood pressure (DBP) (LSM difference: −1.04 mmHg; 95% CI: −1.37 to −0.70; p < 0.001) compared with the placebo, with an absence of statistical heterogeneity (I2 = 0.00%). Subgroup analysis confirmed office SBP-lowering efficacy across different clinical phenotypes, including chronic kidney disease and heart failure (p for interaction = 0.18). In a small subset of patients, finerenone reduced 24-h ambulatory SBP (LSM difference: −7.88 mmHg; 95% CI: −10.94 to −4.82; p < 0.001), though these exploratory findings warrant caution due to the limited sample size; no significant reduction was observed for 24-h ambulatory DBP. Conclusions: Finerenone is associated with a modest but statistically significant reduction in systemic SBP.