<p>Resistant hypertension is conventionally defined as failure to achieve blood pressure control despite treatment with optimal or maximally tolerated doses of three antihypertensive drugs, typically including a renin–angiotensin system blocker, a calcium channel blocker, and a diuretic. In real-world practice, however, many patients receive four or more antihypertensive agents without necessarily fulfilling classical resistant hypertension criteria, and data describing such prescribing patterns among cardiologists are limited. We conducted a prospective, multicentre, cross-sectional observational study across 10 cardiology outpatient centres enrolling consecutive adult patients (≥ 18 years) receiving more than three antihypertensive drugs. Patients with renal denervation, renal transplantation, known renal artery stenosis, or incomplete data were excluded. Demographic characteristics, blood pressure, comorbidities, and antihypertensive prescriptions were recorded, with a predefined analysis of mineralocorticoid receptor antagonist (MRA) use in the overall cohort and in patients meeting guideline criteria for resistant hypertension. A total of 420 patients were included (mean age 65.2 years; male-to-female ratio 1:0.8). Renin–angiotensin system inhibitors, calcium channel blockers, and diuretics were prescribed in 89, 85, and 82% of patients, respectively, while beta-blocker use was high at 85%. Overall MRA use was low at 39%. Among patients fulfilling criteria for resistant hypertension (n = 273), MRA use was 27%, increasing to only 38% when serum potassium was ≤4.5 mEq/L. Serum potassium ≤4.5 mEq/L was the only independent predictor of MRA prescription. These findings highlight substantial underutilization of MRAs in real-world practice and an important opportunity to improve guideline-directed management of resistant hypertension.</p><p></p>