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Background Arterial hypertension is highly prevalent and frequently difficult to control in patients with obstructive sleep apnea (OSA). High sympathetic activity is a hallmark physiological phenomenon in OSA. We hypothesized that antihypertensive drugs with sympathetic inhibitory properties, in particular beta blockers (BB), may be particularly efficacious in OSA patients. Methods Hypertensive OSA patients receiving blood pressure lowing treatment in the European Sleep Apnea Database (ESADA) were analyzed (n=5818, 69% men, age 58±11 years, body mass index 33±7 kg/m2, apnea hypopnea index 34±26 events/h). Antihypertensive medications (BB, diuretic, renin-angiotensin blocker [RAB], calcium channel blocker [CCB], and centrally acting antihypertensive [CAH]) were classified according to ATC code. Office blood pressure was compared in patients with mono- or combination therapy controlling for confounders. Results Poorly controlled systolic blood pressure according to the ESC/ESH guidelines was found in 66% of patients. Patients receiving monotherapy with RAB, CCB or CAH had 2.2 [95% CI, 1.4–3.0], 3.0 [1.9–4.1] and 3.0 [1.7–4.7] mmHg higher systolic blood pressure compared with those on BB (adjusted model, p=0.007, 0.008 and 0.017, respectively). In those with a combination of two antihypertensive drugs, systolic blood pressure was 3.3 [2.4–4.3], 2.2 [1.3–4.3] and 2.3 [1.4–3.3] mmHg higher in those on CCB/RAB, diuretic/RAB or BB/RAB compared with those on BB/diuretic (adjusted model, p&amp;lt;0.001, 0.019 and 0.001, respectively). Conclusions Uncontrolled blood pressure was common in OSA patients with antihypertensive medication. Patients treated with BB alone or in combination with diuretic was associated with a lower systolic pressure in this large clinical cohort. Funding Acknowledgement Type of funding source: Other. Main funding source(s): European Respiratory Society funded Clinical Research Collaboration (2015-2020)

Superior hypertension control with betablockade in the European Sleep Apnea Database