Adverse effect of beta-blockers in non-ST elevation acute coronary syndrome patients with obstructive sleep apnea

Background: Currently, beta-blockers are recommended for non-ST elevation acute coronary syndrome (NSTE-ACS). However, there is still a lack of studies evaluating the use of beta-blockers in patients with NSTE-ACS complicated by obstructive sleep apnea (OSA). Methods: This is the sub-analysis of OSA-ACS project (NCT03362385), a prospective, observational study recruited ACS patients undergoing portable sleep monitoring between June 2015 and January 2020. Patients with NSTE-ACS were selected in this analysis. The primary endpoint was major adverse cardiovascular events (MACE), including cardiovascular death, myocardial infarction or ischemia-driven revascularization. Results: After exclusion, 1452 NSTE-ACS patients were enrolled, and 75.3 % of patients received beta-blockers at discharge. The proportion of beta-blockers users in the OSA group was 77.4 % and 73.2 % in the non-OSA group, with no significant difference (P = 0.068). In OSA group, beta-blocker users had higher rate of MACE (18.2 % versus 9.0 %, adjusted hazard ratio [HR] 1.90, 95 % confidence interval [CI] 1.04-3.45, p = 0.037) but not in non-OSA group (14.1 % versus 9.9 %, adjusted HR 1.45, 95 % CI 0.80-2.62, p = 0.219). After propensity score matching, beta-blocker users were still at higher risk of MACE (19.3 % versus 9.3 %, adjusted HR 2.18, 95 % CI 1.09-4.35, p = 0.028) in OSA group, in contrast the risk was comparable in non-OSA group (13.2 % versus 9.9 %, adjusted HR 1.27, 95 % CI 0.63-2.57, p = 0.501). Sensitivity analysis was consistent with the main results. Subgroup analysis showed no significant interactions (P > 0.10, for all comparisons). Conclusion: The administration of beta-blockers is associated with higher risk of adverse cardiovascular outcomes in NSTE-ACS patients with concomitant OSA.