INTRODUCTION: Obstructive Sleep Apnea (OSA) is a prevalent condition affecting millions worldwide and is associated with an increased risk of cardiovascular complications, including ST-Elevation Myocardial Infarction (STEMI). The relationship between OSA and STEMI is complex, with OSA potentially exacerbating the severity of coronary artery disease and influencing outcomes following acute coronary events. METHODS: We retrospectively analyzed data from the National Inpatient Sample database from 2016 to 2021. Hospitalized patients aged 18 and older diagnosed with STEMI were included. Key outcomes, such as in-hospital mortality, cardiac interventions and inpatient complications, were compared between those with and without OSA. Propensity score matching was utilized to account for potential confounders and risk of complications was compared. RESULTS: Among 1,203,915 STEMI hospitalizations, 75,035 (6.2%) had OSA. After PSM, OSA was associated with lower in-hospital mortality (aOR: 0.82, 95% CI: 0.76-0.89, p <
0.001) but higher risks of atrial fibrillation (aOR: 1.28, 95% CI: 1.21-1.36, p <
0.001), venous thromboembolism (aOR: 1.23, 95% CI: 1.06-1.44, p = 0.009), acute kidney injury (aOR: 1.10, 95% CI: 1.04-1.16, p = 0.001), and second-degree atrioventricular block (aOR: 1.69, 95% CI: 1.33-2.15, p <
0.001). OSA patients were more likely to require non-invasive ventilation (aOR: 2.78, 95% CI: 2.48-3.11, p <
0.001) but less likely to need invasive ventilation (aOR: 0.91, 95% CI: 0.84-0.96, p <
0.001) or vasopressors (aOR: 0.77, 95% CI: 0.68-0.87, p = 0.001). Female STEMI patients with OSA had higher mortality than males (aOR: 1.17, 95% CI: 1.14-1.20, p <
0.001) and underwent fewer invasive interventions. CONCLUSION: OSA in STEMI patients was associated with lower in-hospital mortality but a higher burden of complications, emphasizing the need for proactive risk stratification. The increased reliance on non-invasive ventilation highlights distinct management patterns. Additionally, the significant sex disparity, with higher mortality and fewer interventions in women, underscores the need for tailored, evidence-based strategies.