Shoulder arthroplasty outcomes in hypertensive patients: a propensity score-matched comparison of angiotensin receptor blockers and angiotensin-converting enzyme inhibitors.

BACKGROUND

Hypertension is a highly prevalent comorbidity among patients undergoing total shoulder arthroplasty (TSA), and angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) are among the most commonly prescribed antihypertensive medications. Emerging evidence suggests that ARBs may confer musculoskeletal benefits, including improved bone quality and reduced fracture risk, compared with ACEIs. The purpose of this study was to evaluate the association between ARB vs. ACEI use and the risk of periprosthetic complications in hypertensive patients undergoing TSA.

METHODS

The TriNetX Global Collaborative Network was queried for hypertensive patients who underwent primary TSA: anatomic total shoulder arthroplasty (aTSA), reverse shoulder arthroplasty (rTSA), and hemiarthroplasty (HA). Patients were stratified by documented perioperative use of ARBs or ACEIs at both timepoints, 6 months before and after surgery. Propensity score matching (1:1) was performed for age, sex, body mass index, HbA1c, smoking status, osteoporosis, rheumatoid arthritis, and comorbidities included in the Charlson Comorbidity Index. Outcomes included medical complications, surgical complications, readmission, emergency department visits, and revision rates, assessed at 90 days, 1, and 2 years postoperatively. Kaplan-Meier analyses evaluated survivorship free from dislocation, stiffness, and periprosthetic fracture (PPFx).

RESULTS

After matching, 11,603 patients were included in both ARB and ACEI cohorts. Further stratification by arthroplasty type yielded matched cohorts of 1,559 aTSA, 3,734 rTSA, and 412 HA patients in both ARB and ACEI cohorts. ARB usage was associated with significantly decreased rates of dislocation at 90 days (OR 0.657; P = .014), 1 year (OR 0.793; P = .030), and 2 years (OR 0.668; P = .002). Similarly, PPFx rates were significantly reduced in the ARB cohort at 90 days (OR 0.674; P = .003), 1 year (OR 0.709; P = .003), and 2 years (OR 0.733; P = .004). Additionally, the risk of stiffness was significantly reduced in the ARB cohort at 1 (OR 0.793; P = .030) and 2 years (OR 0.778; P = .013). Subgroup analyses by arthroplasty type demonstrated a significantly decreased risk of PPFx among ARB users undergoing rTSA (OR 0.713; P = .027) and HA (OR 0.447; P = .016) at 2 years.

CONCLUSIONS

Among hypertensive patients undergoing TSA, ARB usage was associated with lower risk of PPFx, dislocation, and stiffness compared with ACEI therapy, without differences in revision or medical complications. Although these findings suggest that ARBs may offer musculoskeletal advantages in the perioperative management of patients undergoing TSA, the observed associations were not consistently reproduced in the procedure-specific subgroups and warrant further prospective investigation.