In an analysis from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) bleeding rates were lowest in patients with admis- sion SBP between 120 and 180 mmHg and increased progres- sively with BPs above and below these ranges. Similarly, in the NCDR ACTION Registry Bleeding Risk Score, zero points are awarded for an SBP of 141 to 170 mmHg on arrival, with 2 points given for SBP >200 mmHg and 4 points for SPB 90 In contrast, BP variables did not emerge as indepen- dently associated with bleeding in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) and Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trials.186 These studies have important limitations that make it difficult to determine the impact of treating hypertension during an acute ACS episode. All of the data are observational, and it is likely that residual confounding explains some, if not most, of the observed adverse association between lower BP and mortality after ACS, particularly for BP values within or near the normal range. In addition, very limited information is available from these studies on the duration of and long-term disease burden of hypertension. Despite these limitations, the consistent asso- ciations observed between hypotension and both mortality and bleeding suggest that avoidance of hypotension should be an important treatment principle in ACS patients. 5.2. 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. 