The prevalence of hypertension appears to be around 30–54% of the general population but only one third of the patients are under control. Hypertension is defined as resistant to treatment when a therapeutic strategy that includes appropiate lifestyle measures plus a diuretic and two other antihypertensive drugs belonging to different classes at adequate doses. It is assosiated with high risk of cardiovascular morbidity and mortality. Denervation of renal sympathetic nerves with radiofrequency ablation catheter is a new nondrug, therapeutic approach in the treatment of resistant hypertension (RH) [1]. Recent guidelines for the management of arterial hypertension addressed renal sympathetic denervation (RSD) as a Class IIb recommendation for the patients with truly RH (clinic BP ≥ 160/ 110 mm Hg confirmed by ambulatory BP monitoring) [1,2]. Up to date, the effectiveness of RSD was evaluated in a couple of studies which were mostly observational and without a control group. When the antihypertensive medicines of the patients before the procedure were investigated, only five reports expressed the number and percentage of the patients that were already receiving a mineralocorticoid receptor antagonist (MRA) (Table 1) [3–7]. Approximately one out of five patients was on MRA therapy and none of these studies provided subgroup analysis regarding the effect of MRA use on BP response after RSD. Insufficient use MRA in RSD trials is quite confusing. Elevated levels of plasma aldosterone were reported in patients with RH and MRAs are the specific drug in the treatment algoritm of hypertensive patients who are referred for resistance. Addition of a MRA to medical therapy in these patients reduced BP significantly in the randomized, double-blind, placebocontrolled ASPIRANT (Addition of Spironolactone in Patients with Resistant Arterial Hypertension) trial [8]. Current guidelines recommend adding an aldosterone antagonist to treat RH as fourth-line therapy. Furthermore, French expert consensus on RSD published in 2012 was proposed the use of spiranolactone (at a dose ≥ 25 mg/d) mandatory before referring patients to the procedure [9]. Ongoing Renal Denervation in Hypertension (DENER-HTN) trial is aimed to examine the efficacy of renal denervation vs a standardized optimized treatment that will include spironolactone 25 mg/d [10]. In conclusion, physicians caring patients with RH should add a MRA to medical therapy before referring the patient to an invasive procedure such as RSD. The RSD procedure should be limited to patients with essential hypertension uncontrolled by four or more antihypertensive therapies including a MRA i.e. spironolactone, even at low doses (25–50 mg/d). The authors of this manuscript have certified that they comply with the principles of ethical publishing in the International Journal of Cardiology.