The BP may fluctuate early after ACS; thus, efforts should focus on pain control and clinical stabilization before BP is specifically targeted. Second, the BP should be lowered slowly, and caution is advised to avoid decreases in DBP to <60 mmHg because this may reduce coronary perfusion and worsen ischemia. A BP target of <130/80 mmHg at the time of hospital discharge is a reasonable option. In older hypertensive individu- als with wide pulse pressures, lowering SBP may lead to very low DBP values, contributing to worsening myocardial ischemia. 5.3. Specific Antihypertensive Agents in ACS Nitroglycerin has been a cornerstone of therapy for decades, and in the hypertensive patient withACS, nitroglycerin is effective in relieving symptoms of ischemia and pulmonary congestion and is moderately effective in lowering arterial BP. However, clinical trial evidence does not support an effect of nitrates on outcomes in ACS. The Gruppo Italiano per lo Studio della Sopravvivenza nell Infarto Miocardico (GISSI)-3 and International Study of Infarct Survival (ISIS)-4 trials included almost 80000 patients with STEMI and found no difference in mortality with the use of nitrates (7.0% for those treated versus 7.2% who received pla- Thus, the ACC/AHA guidelines for STEMI do not recommend nitroglycerin to reduce events but only to relieve ischemic pain or acute hypertension or to manage pulmonary congestion at a Level of Evidence C. Nitrates should be used with caution in patients with inferior STEMI and are contraindicated if right ventricular infarction is present because of their effects on low- ering preload. 