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Treatment-resistant hypertension is associated with an increased risk of cardiovascular morbidity and mortality. Treatment recommendations include a combination of at least three antihypertensive drug classes, including a diuretic. Although there is limited evidence to support selection of add-on therapy, mineralocorticoid receptor antagonists (e.g. spironolactone and eplerenone) can effectively reduce blood pressure when added to standard combination therapy, and should be considered as fourth-line treatment options.