Guía basada en la evidencia para el manejo perioperatorio de la anticoagulación oral con warfarina en pacientes con alto riesgo embólico que serán llevados a implante de dispositivos de estimulación cardiaca

Introduction: The perioperative management of chronic anticoagulation concerns all physicians involved in the implantation of cardiac electronic devices (either pacemakers and cardioverter-defibrillators). Switching from warfarin to low molecular weight heparins (LMWH) has been performed to reduce the risk of bleeding. However, this approach has been shown to be controversial. Objective: To generate evidence-based recommendations on the perioperative management oforal anticoagulation with warfarin in patients who will undergo the implantation of a cardiacelectronic device.Methods: A literature search was performed to identify evidence-based clinical practice guidelines, which were assessed using the AGREE II instrument. The guidelines were updated withsystematic reviews and randomized clinical trials published from February 2009 to November 2013 comparing the continuation of warfarin versus switching to a LMWH or withholding warfarin. These studies were analyzed using the SIGN and GRADE scales to assess methodological quality. Recommendations were put forward through an expert panel. Results: The guidelines with highest methodological quality were the SIGN (Scottish Intercollegiate Guidelines Network) guideline published in June 2013 and the CHEST guideline publishedin February 2012. The update included three systematic reviews and two randomized clinicaltrials. The continuation of warfarin for the perioperative management of implantable cardiacelectronic devices in patients with moderate and high risk is recommended.Conclusion: Based on the new evidence changes the recommendation given by the CHEST SIGN and guides. The alternative of continued therapy with warfarin in exchange for performingtherapy bridge, should be considered in clinical practice.