Scottish Intercollegiate Guidelines Network Guidelines Research Articles

Guideline summary: assessment, diagnosis, care and support for people with dementia and their carers [Scottish Intercollegiate Guidelines Network SIGN Guideline 168

The Scottish Intercollegiate Guidelines Network (SIGN) have recently published their guideline SIGN168 on 'Assessment, Diagnosis, Care, and Support for People with Dementia and their Carers'. The guideline makes evidence-based recommendations for best practice in the assessment, care and support of adults living with dementia. Topics featured in this guideline are limited to those prioritised by stakeholders, especially people with lived and living experience, and those not well covered under pre-existing guidance. We summarise the guideline recommendations related to identification and diagnosis of dementia, investigative procedures, postdiagnostic support living with dementia, including non-pharmacological approaches for distressed behaviours, using technology to support people with dementia, grief and dementia and changing needs of people with dementia. The guideline content is summarised as officially published, with additional commentary in the final section.

Scottish Intercollegiate Guidelines Network Guidance on Dementia: The Investigation of Suspected Dementia (SIGN 168) with Focus on Biomarkers-Executive Summary.

This is an executive summary of the recent guidance produced by the Scottish Intercollegiate Guidelines Network (SIGN) dementia guideline group with regards to the investigation of suspected dementia. This is a sub-section of the broader SIGN 168 guideline released in November 2023. The guideline group included clinicians with expertise in Old Age Psychiatry, Neurology, Radiology, and Nuclear Medicine supported by colleagues from the SIGN and Healthcare Improvement Scotland teams. There was representation from carers and support organizations with experience of dementia, to ensure the recommendations were appropriate from the perspective of the people being assessed for possible dementia and their carers. As the 2018 National Institute for Health and Clinical Excellence (NICE) dementia review included a review of the evidenced investigation of dementia, the SIGN guideline development group decided to focus on a review on the up-to-date evidence regarding the role of imaging and fluid biomarkers in the diagnosis of dementia. To give context to the consideration of more advanced diagnostic biomarker investigations, the guideline and this summary include the NICE guidance on the use of standard investigations as well as more specialist investigations. The evidence review supports consideration of the use of structural imaging, nuclear medicine imaging, and established Alzheimer's cerebrospinal fluid biomarkers (amyloid and tau) in the diagnosis of dementia. Although routine use of amyloid positron emission tomography imaging was not recommended, its potential use, under specialist direction, in patients with atypical or young-onset presentations of suspected Alzheimer's dementia was included as a clinical good practice point.

Adherence to National Asthma Guidelines in the Acute Care Setting: A Retrospective Cohort Study.

Peak flow is a crucial but simple test used to categorize the severity of an episode of an acute exacerbation of asthma.It should be regularly done in all the patients who present with asthma acute exacerbation in the emergency department. The British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) guidelines stipulate peak flow use as one of the main tools to categorize acute asthma into moderate, severe, and life-threatening asthma. The BTS and SIGN guidelines also state peak flow is to be utilized in monitoring the disease and to guide in treating patients with acute asthma. This study aims to identify the adherence to BTS/SIGN guidelines around the use of peak expiratory flow rate (PEFR) in assessing the severity of patients presenting with acute exacerbation of asthma in a district general hospital. The retrospective cohort study involved collating data between October 2022 and February 2023 from our hospital electronic system. The data collected about the use of PEFR and whether the patients were being classified by severity in presentation following this was compared to the BTS/SIGN 158 asthma guidelines. Following this, the data analysis was done using IBM SPSS Statistics for Windows, Version 21.0 (Released 2012; IBM Corp., Armonk, New York, United States). Data from 92 patients were collated. PEFR was recorded for 29.3% (n=27) of patients and acute exacerbation of asthma severity was documented in merely 17.4% (n=16) patients. The results indicate a significant proportion of the patient cohort analyzed did not have peak flow readings, there is clear room for improvement, and further intervention is needed in order for the department to adhere to the gold standard guidelines (i.e., BTS/SIGN 158), and thus improve the management and monitoring of acute asthma exacerbations. Future directions can include departmental education, posters as a reminder, and prompts on the electronic system used to alert users to check PEFR when a diagnosis of acute asthma exacerbation is documented.

A proposed methodology for uncertainty extraction and verification in priority setting partnerships with the James Lind Alliance: an example from the Common Conditions Affecting the Hand and Wrist Priority Setting Partnership

BackgroundTo report our recommended methodology for extracting and then confirming research uncertainties – areas where research has failed to answer a research question – derived from previously published literature during a broad scope Priority Setting Partnership (PSP) with the James Lind Alliance (JLA).MethodsThis process was completed in the UK as part of the PSP for “Common Conditions Affecting the Hand and Wrist”, comprising of health professionals, patients and carers and reports the data (uncertainty) extraction phase of this. The PSP followed the robust methodology dictated by the JLA and sought to identify knowledge gaps, termed “uncertainties” by the JLA. Published Cochrane Systematic Reviews, Guidelines and Protocols, NICE (National Institute for Health and Care Excellence) Guidelines, and SIGN (Scottish Intercollegiate Guidelines Network) Guidelines were screened for documented “uncertainties”. A robust method of screening, internally verifying and then checking uncertainties was adopted. This included independent screening and data extraction by multiple researchers and use of a PRISMA flowchart, alongside steering group consensus processes.Selection of research uncertainties was guided by the scope of the Common Conditions Affecting the Hand and Wrist PSP which focused on “common” hand conditions routinely treated by hand specialists, including hand surgeons and hand therapists limited to identifying questions concerning the results of intervention, and not the basic science or epidemiology behind disease.ResultsOf the 2358 records identified (after removal of duplicates) which entered the screening process, 186 records were presented to the PSP steering group for eligibility assessment; 79 were deemed within scope and included for the purpose of research uncertainty extraction (45 full Cochrane Reviews, 18 Cochrane Review protocols, 16 Guidelines). These yielded 89 research uncertainties, which were compared to the stakeholder survey, and added to the longlist where necessary; before derived uncertainties were checked against non-Cochrane published systematic reviews.ConclusionsIn carrying out this work, beyond reporting on output of the Common Conditions Affecting the Hand and Wrist PSP, we detail the methodology and processes we hope can inform and facilitate the work of future PSPs and other evidence reviews, especially those with a broader scope beyond a single disease or condition.

Twenty-year observational study of paediatric tonsillitis and tonsillectomy

IntroductionTonsillectomy is now only indicated in the UK when specific criteria are met, as outlined by the Scottish Intercollegiate Guidelines Network (SIGN) and The National Institute for Health and Care...

Socioeconomic Deprivation: An Important, Largely Unrecognized Risk Factor in Primary Prevention of Cardiovascular Disease.

Background:Socioeconomic deprivation is associated with higher cardiovascular morbidity and mortality. Whether deprivation status should be incorporated in more cardiovascular risk estimation scores remains unclear. This study evaluates how socioeconomic deprivation status affects the performance of 3 primary prevention cardiovascular risk scores.Methods:The Generation Scotland Scottish Family Health Study was used to evaluate the performance of 3 cardiovascular risk scores with (ASSIGN [Assessing cardiovascular risk using SIGN (Scottish Intercollegiate Guidelines Network) guidelines to ASSIGN preventive treatment]) and without (SCORE2 [Systematic Coronary Risk Evaluation 2 algorithm], Pooled Cohort Equations) socioeconomic deprivation as a covariate in the risk prediction model. Deprivation was defined by Scottish Index of Multiple Deprivation score. The predicted 10-year risk was evaluated against the observed event rate for the cardiovascular outcome of each risk score. The comparison was made across 3 groups defined by the deprivation index score consisting of group 1 defined as most deprived, group 3 defined as least deprived, and group 2, which consisted of individuals in the middle deprivation categories.Results:The study population consisted of 15 506 individuals (60.0% female, median age of 51). Across the population, 1808 (12%) individuals were assigned to group 1 (most deprived), 8119 (52%) to group 2, and 4708 (30%) to group 3 (least deprived), and 871 (6%) individuals had a missing deprivation score. Risk scores based on models that did not include deprivation status significantly under predicted risk in the most deprived (6.43% observed versus 4.63% predicted for SCORE2 [P=0.001] and 6.69% observed versus 4.66% predicted for Pooled Cohort Equations [P<0.001]). Both risk scores also significantly overpredicted the risk in the least deprived group (3.97% observed versus 4.72% predicted for SCORE2 [P=0.007] and 4.22% observed versus 4.85% predicted for Pooled Cohort Equations [P=0.028]). In contrast, no significant difference was demonstrated in the observed versus predicted risk when using the ASSIGN risk score, which included socioeconomic deprivation status in the risk model.Conclusions:Socioeconomic status is a largely unrecognized risk factor in primary prevention of cardiovascular disease. Risk scores that exclude socioeconomic deprivation as a covariate under- and overestimate the risk in the most and least deprived individuals, respectively. This study highlights the importance of incorporating socioeconomic deprivation status in risk estimation systems to ultimately reduce inequalities in health care provision for cardiovascular disease.

The Impact of COVID-19 on Physical Health Monitoring of Community Rehabilitation Team Patients in NHS Borders

AimsPeople with schizophrenia have a life expectancy that is 10–20 years shorter than the general population. The high incidence of metabolic syndrome, cardiovascular disease and diabetes mellitus in this patient group are thought to be major – and potentially modifiable – factors contributing to this premature mortality. Therefore, annual monitoring of physical health parameters is recommended by organisations including the Scottish Intercollegiate Guidelines Network (SIGN). The SIGN guideline on schizophrenia advises that the following parameters are checked annually for patients with schizophrenia who are on anti-psychotics: ECG, blood glucose, lipid profile, prolactin, BMI/weight, smoking status and blood pressure. Traditionally, this monitoring is overseen in the community by general practitioners. This audit aimed to capture how the COVID-19 pandemic impacted on the annual physical health monitoring of patients under the care of NHS Borders Community Rehabilitation Team.MethodsA retrospective audit was performed by reviewing notes of the 100 patients on the NHS Borders Community Rehabilitation team caseload. Notes from the years of 2019, 2020 and 2021 of all 100 patients on the caseload were reviewed, for documentation of the following seven parameters as recommended by SIGN: ECG, blood glucose, lipid profile, prolactin, BMI/weight, smoking status and blood pressure. Results were then entered manually into a secure spreadsheet. Permission for this audit was granted by NHS Borders.ResultsInitial results for the parameters of: ECG, blood glucose, lipid profile and prolactin levels demonstrate that routine monitoring of all four domains has decreased since the start of the COVID-19 pandemic. In 2019 the following numbers of patients had monitoring in these domains: ECG 56 (56%); blood glucose 84 (84%); lipid profile 74 (74%) and prolactin levels 62 (62%).During 2020, the number of patients having monitoring in all four domains fell: ECG 31 (31%); blood glucose (72%); lipid profile 64 (64%) and prolactin levels 48 (48%). During 2021, monitoring levels remained low: ECG 30 (30%); blood glucose 71 (71%); lipid profile 62 (62%) and prolactin levels 43 (43%).Data collection for the parameters of blood pressure, BMI/weight and smoking status is ongoing.ConclusionInitial results indicate that the COVID-19 pandemic has negatively impacted on the routine physical health monitoring of patients under the care of the community rehabilitation team in NHS Borders. These results imply opportunities to treat and prevent conditions such as diabetes mellitus and hypercholesterolemia are being missed, further perpetuating an existing health inequality for patients with severe and enduring mental illness.

Evaluation of evidence grades in psychiatry and psychotherapy guidelines

BackgroundInformation regarding the distribution of evidence grades in psychiatry and psychotherapy guidelines is lacking. Based on the German evidence- and consensus- based (S3) psychiatry and psychotherapy and the Scottish Intercollegiate Guidelines Network (SIGN) treatment guidelines, we aimed to specify how guideline recommendations are composed and to what extent recommendations are evidence-based.MethodsData was collected from all published evidence- and consensus-based S3-classified psychiatry and psychotherapy guidelines. As control conditions, data from German neurology S3-classified guidelines as well as data from recent SIGN guidelines of mental health were extracted. Two investigators reviewed the selected guidelines independently, extracted and analysed the numbers and levels of recommendations.ResultsOn average, 45.1% of all recommendations are not based on strong scientific evidence in German guidelines of psychiatry and psychotherapy. A related pattern can be confirmed for SIGN guidelines, where the mean average of recommendations with lacking evidence is 33.9%. By contrast, in the German guidelines of neurology the average of such recommendations is 16.5%. A total of 24.5% of all recommendations in the guidelines of psychiatry and psychotherapy are classified as level A recommendations, compared to 31.6% in the field of neurology and 31.1% in the SIGN guidelines. Related patterns were observed for B and 0 level recommendations.ConclusionGuidelines should be practical tools to simplify the decision-making process based on scientific evidence. Up to 45% of all recommendations in the investigated guidelines of psychiatry and psychotherapy are not based on strong scientific evidence. The reasons for this high number remain unclear. Possibly, only a limited number of studies answer clinically relevant questions. Our findings thereby question whether guidelines should include non-evidence-based recommendations to be methodologically stringent and whether specific processes to develop expert-opinion statements must be implemented.

Ranolazine in refractory and chronic stable angina

Aim/Objectives: The current Scottish Intercollegiate Guidelines Network (SIGN) guidelines recommend beta blockers and dihydropiridine calcium channel blockers as first-line agents for refractory angina pectoris. Despite being optimally treated with pharmacotherapy and revascularisation, up to 40% of patients still experience symptoms. Ranolazine, a piperazine derivative, selectively inhibits late sodium currents and is of particular interest as it is currently not recommended routinely by SIGN guidelines and Scottish Medicine Consortium (SMC) but has been prescribed in Tayside, initially through IPTR since 2017 and recently through a Local New Medicine Treatment Protocol and Stable Angina Pathway. Real world experience of ranolazine prescribing in patients with chronic and often refractory angina is not widely reported. We therefore audited its use in Tayside to understand its prescribing pattern within our patient population and assess its effects on angina symptom relief. Methods: Electronic health records and prescribing data between 1st January 2012 and 31st December 2018 were retrospectively analysed. Data on baseline characteristics, prescribing information, past medical history, and angina symptom control were collected. Standard descriptive statistics were used for analysis. Results: 35 patients were identified as suitable for inclusion in the audit. Mean age was 71.4 ± 12.5 years old and 68.6% were male. 23 patients (65.7%) had either a previous percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). The most common reason for ranolazine prescription was refractory angina (74.3%) with 375 mg BD being the most common dose. Prescription of guideline-recommended anti anginals was high with 80% of patients being on a beta blocker and a nitrate prior to commencing ranolazine. Encouragingly, 27 patients (77.1%) reported an improvement in Canadian Cardiovascular Society (CCS) angina class and the rate of non-responders was 22.9%. No adverse effects leading to discontinuation of ranolazine was found. Conclusion: Ranolazine may play a role as an additional anti anginal agent with reasonable achievement of symptom control in patients who have refractory angina despite the use of other guideline-recommended anti anginal agents.

The management of urinary tract infections in a district general hospital – a closed loop service review and comparison with SIGN guidelines

Elderly patients with new onset of confusion or being ‘off legs’ is a common presenting complaint on the acute take. Urinary tract infections (UTI) are common in the elderly population, often a diagnosis is made based on a positive urine dipstick in the absence of urinary symptoms. However, these patients may actually have asymptomatic bacteriuria (AB). The prevalence of AB in institutionalised women above the age of 65 have been reported to be as high as 57%.1 Bacteriuria is not a disease, and treating it is not advised under the Scottish Intercollegiate Guidelines Network (SIGN) guidelines.2 We looked …

The Scottish Intercollegiate Guidelines Network: risk reduction and management of delirium.

Clinical and research interest in delirium has been rising over the last 15 years. The Scottish Intercollegiate Guidelines Network (SIGN) publication on delirium is a state-of-the-art synthesis of the field, and the first UK guideline since 2010. There is new guidance around delirium detection, particularly in recommending the 4 'A's Test (4AT). The 4AT has the advantage of being brief, embeds and operationalises cognitive testing, and is scalable with little training. The guidelines highlight the importance of non-pharmacological management for all hospital presentations involving the spectrum of cognitive disorders (delirium, dementia but at risk of delirium, delirium superimposed on dementia). Pharmacotherapy has a minimal role, but specific indications (e.g. intractable distress) are discussed. Advances in delirium research, education and policy, have come together with steady changes in the sociocultural context in which healthcare systems look after older people with cognitive impairment. However, there remains a gap between desired and actual clinical practice, one which might be bridged by re-engaging with compassionate, patient-centred care. In this respect, these SIGN guidelines offer a key resource.

Impact of the SIGN head injury guidelines and NHS 4-hour emergency target on hospital admissions for head injury in Scotland: an interrupted times series

ObjectivesHead injury is a common reason for emergency department (ED) attendance. Around 1% of patients have life-threatening injuries, while 80% of patients are discharged. National guidelines (Scottish Intercollegiate Guidelines Network...

Assessing antibiotic stewardship using the surgical site infection prevention bundle.

Antibiotic prophylaxis is crucial in head and neck surgery to prevent infection from clean contaminated wounds. Scottish Intercollegiate Guidelines Network (SIGN) guidance, the gold standard of practice, recommends that administration of broad spectrum antibiotics is discontinued after 24 hours post-operation. A three-audit cycle quality improvement project was conducted to assess clinical practice against SIGN guidance at a large London teaching hospital. Three change initiatives were implemented to improve antibiotic stewardship. First, an update of Trust guidelines with an associated poster campaign to educate staff and improve awareness. Second, introduction of a specific 'prophylactic antibiotics in head and neck surgery' bundle on the electronic hospital-wide prescribing system. Third, an update to an antibiotic prescribing guide (Microguide). Over a 3-year study period the number of patients receiving antibiotics beyond 24 hours declined significantly (88% in 2015, 76% in 2016, 25% in 2018), demonstrating improved compliance with SIGN guidelines overall. Despite this, staff documentation of indications for extended antibiotic use remains suboptimal (58% in 2016 and 44% in 2018) as does the number of specimens sent for microbiological analysis (52% in 2016 and 0% in 2018). Appropriate prophylactic antibiotic prescribing can improve morbidity and mortality rates in head and neck cancer patients. Three change initiatives have been demonstrated which can help to improve prescribing compliance in line with SIGN guidance. Ongoing auditing is required to maintain the longevity of improvements made and encourage staff documentation of indications for extended antibiotic use and microbiology specimen analysis.

The impact of SIGN glaucoma guidelines on false-positive referrals from community optometrists in Central Scotland

BackgroundSince the introduction of National Institute for Health and Care Excellence glaucoma guidelines 2009, the number of referrals from community optometrists to hospital eye services has increased across the UK,...

Compliance with the 62-day target does not improve long-term survival.

Scottish Intercollegiate Guidelines Network (SIGN) guidelines require patients with colorectal cancer to wait no longer than 62days from first referral to initiation of definitive treatment. We previously demonstrated that failure to meet with these guidelines did not appear to lead to poor outcomes in the short term. This study investigates whether this holds true over a longer period. The survival status of 1,012 patients treated for colorectal cancer between January 1999 and June 2005 was reviewed. As in the previous audit, patients were placed into four groups, standard met (elective), standard met (emergency), standard failed (elective) and standard failed (emergency). Parameters analysed were pathological staging, 30-day mortality, long-term survival and cause of death. Data was analysed using log rank and chi-squared tests. Operative mortality was higher in patients meeting the standard (7% elective, 20% emergency) compared to those who did not meet the standard (4% elective, 7% emergency). The proportion of early stage disease (Dukes' A and B) was highest in elective patients who failed the standard (50%) and lowest in emergencies meeting the standard (30%). Long-term survival was greatest in elective patients who failed the standard with 52% alive in October 2011 compared to 34% of elective cases meeting the standard. The most common cause of recorded death was colorectal cancer in all groups. Patients who were not treated within the time frame set by the SIGN guidelines survived for longer following surgery. Reasons for this are likely to be multifactorial and include pathological cancer stage.

Evaluation of guidelines regarding surgical treatment of breast cancer using the AGREE Instrument: a systematic review

ObjectivesMany clinical practice guidelines and consensus statements (CPGs/consensus statements) have been developed for the surgical treatments for breast cancer. This study aims to evaluate the quality of these CPGs/consensus statements.MethodsWe...

Assessment of rational use of antibiotics in surgical prophylaxis and post- operative cases at district hospital Gulbarga

Background: Postoperative wound infections are the major cause of morbidity in surgical patients. The use of pre and peri-operative antibiotics, with sound and appropriate principles of prophylaxis are applied can result in a reduced risk of postoperative infection. Although the principles of antimicrobial prophylaxis for surgical procedures have been well defined for many years, inappropriate and excessive use of antimicrobials for this purpose remains widespread.Methods: This was a prospective study conducted on the inpatients undergoing surgical procedures. ASHP (American Society of Health System Pharmacists) and SIGN (Scottish Intercollegiate Guidelines Network) guidelines were used as the standard guideline.Results: Of the total 150 procedures reviewed, 130 procedures were entered in the analysis. Of these procedures, the rate of totally compliant prescriptions was 28.46%. Totally in 93 (71.53%) patients, the antibiotic prophylaxis was found to be inappropriate. In 36 (27.70%) patients, indication for antibiotic prophylaxis was not proper and in total 38 (44.19%) patients, where antibiotic prophylaxis was justified and given, proper antimicrobial agent was not used.Conclusions: Instead of existence of the written guidelines for antimicrobial surgical prophylaxis there are significant deviations from the recommendations in current clinical practice. Adherence of antibiotic prophylaxis to these guidelines is needed to be evaluated routinely in clinical practice.

NICE v. SIGN on psychosis and schizophrenia: same roots, similar guidelines, different interpretations.

A recent editorial claimed that the 2014 National Institute for Health and Care Excellence (NICE) guideline on psychosis and schizophrenia, unlike its equivalent 2013 Scottish Intercollegiate Guidelines Network (SIGN) guideline, is biased towards psychosocial treatments and against drug treatments. In this paper we underline that the NICE and SIGN guidelines recommend similar interventions, but that the NICE guideline has more rigorous methodology. Our analysis suggests that the authors of the editorial appear to have succumbed to bias themselves.

Glaucoma-service provision in Scotland: introduction and need for Scottish Intercollegiate Guidelines Network guidelines.

PurposeTo describe the pattern of glaucoma-service delivery in Scotland and identify areas for improvement, taking into account Scottish General Ophthalmic Services (GOS) arrangements and the Eye Care Integration project, and to design Scottish Intercollegiate Guidelines Network (SIGN) guidelines to refine the primary and secondary interface of glaucoma care.Materials and methodsA glaucoma-survey questionnaire was sent to all consultant glaucomatologists in Scotland. The design of SIGN guidelines was based on the results of the questionnaire using SIGN methodology.ResultsOver 90% of Scottish glaucoma care is triaged and delivered within hospital services. Despite GOS referral, information is variable. There are no consistent discharge practices to the community. These results led to defined research questions that were answered, thus formulating the content of the SIGN guidelines. The guideline covers the assessment of patients in primary care, referral criteria to hospital, discharge criteria from hospital to community, and monitoring of patients at risk of glaucoma.ConclusionWith increasing age and limitations to hospital resources, refining glaucoma pathways between primary and secondary care has become a necessity. Scotland has unique eye care arrangements with both the GOS and Eye Care Integration project. It is hoped that implementation of SIGN guidelines will identify glaucoma at the earliest opportunity and reduce the rate of false-positive referrals to hospital.

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

IntroductionThe 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. ObjectiveTo generate evidence-based recommendations on the perioperative management of oral anticoagulation with warfarin in patients who will undergo the implantation of a cardiac electronic device. MethodsA literature search was performed to identify evidence-based clinical practice guidelines, which were assessed using the AGREE II instrument. The guidelines were updated with systematic 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. ResultsThe guidelines with highest methodological quality were the SIGN (Scottish Intercollegiate Guidelines Network) guideline published in June 2013 and the CHEST guideline published in February 2012. The update included three systematic reviews and two randomized clinical trials. The continuation of warfarin for the perioperative management of implantable cardiac electronic devices in patients with moderate and high risk is recommended. ConclusionBased on the new evidence changes the recommendation given by the CHEST SIGN and guides. The alternative of continued therapy with warfarin in exchange for performing therapy bridge, should be considered in clinical practice.