Perioperative antihypertensive medication use is associated with no antifibrotic benefit but higher complications and revision rates following shoulder arthroplasty

PURPOSE: Renin-angiotensin-aldosterone system (RAAS) inhibitors, including angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs), are commonly prescribed antihypertensive medications with proposed antifibrotic and bone-protective effects. Their impact on outcomes following total shoulder arthroplasty (TSA) remains unclear. This study evaluates the association between perioperative RAAS inhibitor exposure and postoperative outcomes after TSA. METHODS: A retrospective cohort study using the TriNetX network identified patients undergoing primary shoulder arthroplasty (2005-2025), stratified by ACEi or ARB use. One-to-one propensity score matching was performed. Outcomes included 90-day medical complications and 1-year mechanical complications and revision. RESULTS: Post-matching, 27,938 patients per cohort (ARB vs. control) and 30,602 per cohort (ACEi vs. control) were included. Neither ARB nor ACEi use reduced rates of manipulation under anesthesia or capsular release at one year. Both cohorts had higher 90-day rates of emergency department visits, readmission, myocardial infarction, and acute renal failure. ACEi use was additionally associated with pulmonary embolism, deep-vein thrombosis, transfusion, and sepsis. At one year, both cohorts showed higher rates of periprosthetic joint infection, aseptic loosening, and revision. Dislocation risk was increased with ACEi use only. CONCLUSION: Perioperative RAAS inhibitor use was not associated lower rates of antifibrotic procedures following TSA. Instead, RAAS inhibitor use was associated with higher rates of several perioperative medical complications and longer-term surgical events, including infection and revision. ACE inhibitor exposure demonstrated a broader complication profile compared with ARB exposure. However, because patients receiving RAAS inhibitors often have greater comorbidity burden, these findings should be interpreted as associative rather than causal. LEVEL OF EVIDENCE III: Retrospective Cohort Study.