General Principles of BP Management in the Patient With ACS The cornerstone of the management of hypertension in patients with ACS is the modification of the balance between myocar- dial oxygen supply and demand. Patients with ACS are espe- cially vulnerable to perturbations in this relationship because the development of an ACS is a clinical manifestation of an alteration in the supply-demand equation such that ischemia occurs at rest or at relatively low levels of demand. Although an elevated BP increases myocardial oxygen demand, rapid and excessive lowering of the DBP has the potential to result in impairment of coronary blood flow and oxygen supply, as discussed in the BP Goals section. In addition, patients with ACS often have vasomotor instability with an increased ten- dency to exaggerated responses to antihypertensive therapy. Because specific trials of BP lowering have not been per- formed in patients with ACS, the selection of antihypertensive agents for use in the patient with ACS should be focused on selecting drugs that have an established evidence-base for risk reduction for patients with ACS independently of BP lower- ing. These drugs, which include -blockers, ACE inhibitors (or ARBs), and, in selected patients, aldosterone antagonists, should typically be titrated to full doses before other agents that do not have an established evidence base are initiated. Therapeutic targets for BP have not been established specifi- cally for patients withACS. Current guidelines recommend a BP target of <140/90 mmHg and <130/80 mmHg for patients with diabetes mellitus or CKD, 1,187 but this applies more to second- ary prevention than the management of hypertension in the acute phase of MI. The BP may fluctuate early after ACS; thus, efforts should focus on pain control and clinical stabilization before BP is specifically targeted. 