Clinical recommendation	Evidence rating	References	Comments
Lifestyle modifications should be recommended for reducing blood pressure, even in patients on multiple medications.	A	4, 5, 28	Sodium restriction was also recently shown to lower cardiovascular events.9
In patients with resistant hypertension, consider screening for primary hyperaldosteronism and obstructive sleep apnea.	C	37–39, 42	These disorders are much more common than other secondary causes, such as pheochromocytoma and coarctation of the aorta.
In patients with resistant hypertension, consider adding spironolactone (Aldactone) to further reduce blood pressure.	C	41	In patients on three or more agents, spironolactone reduces blood pressure an average of 20/10 mm Hg. Attention must be paid to serum potassium and creatinine levels.