Bitcoin is under pressure as ETF outflows and large-scale selling by major investors continue to impact the market, according to a Bitfinex Alpha report. Despite a 20% rebound from its February 5th low, Bitcoin's downtrend persists, with US Bitcoin spot ETFs experiencing a net outflow of $2.6 billion this year. The report highlights that 64% of exchange inflows are from large holders, marking the highest level since October 2015. The market is further influenced by US tariff policies and macroeconomic uncertainties, leading options traders to pay a premium for downside risk. This cautious sentiment underscores the importance of the $53,000 realized price as a key support level for Bitcoin in the medium term.