Development and validation of an LC-MS/MS method for relevant drugs in epilepsy patients using dried blood spots.

Epilepsy is one of the most common diseases of the central nervous system globally. To ensure the correct dosage of antiepileptic treatment, it is helpful to check the blood levels of the administered substances regularly. The analysis of the capillary dried blood samples provides a promising and less-invasive alternative to venous blood collection. Therefore, the aim of the present study was to develop an LC-MS method for the quantification of 22 commonly used drugs in patients with an epileptic syndrome and 5 drug metabolites in one dried blood spot (DBS). The calibration ranges were selected in such a way that the therapeutic reference ranges in serum for the respective substances were completely covered. The analytical validation was successfully performed according to relevant guidelines with a consideration of requirements for DBS analysis. Proof of concept of the developed method was obtained by the analysis of DBSs from 282 authentic leftover ethylenediaminetetraacetic acid blood samples, which were compared with the corresponding serum concentrations. Altogether, the results show a dependency on the blood/plasma (b/p) ratios of the respective analytes so that for drugs with b/p ratios close to one, for example, lacosamide, levetiracetam, brivaracetam, and sertraline, a good accordance was observed.

Development and validation of a mass spectrometric detection method of peginesatide in dried blood spots for sports drug testing.

As recently reported, dried blood spot (DBS) analysis is an advantageous technique for doping control purposes due to the minimal invasive sample collection, the simple and economic manner, as well as the low susceptibility to manipulation. Its general applicability to the sports drug testing arena has been shown for analytes of various substance classes, all of which comprise exclusively low molecular mass compounds. The aim of the present study was to investigate whether the technique of DBS analysis is applicable also to (pegylated) peptides with relevance for doping controls. As target analyte, peginesatide (Omontys, Hematide), a recently approved pegylated erythropoietin-mimetic peptide of approximately 45 kDa, tested for the treatment of anaemia in patients with renal failure, was chosen, which has been prohibited in elite sports due to its assumed endurance enhancing effects. Therefore, a detection method for peginesatide employing DBS was developed based on extraction, proteolytic digestion and cation-exchange purification followed by liquid chromatography-tandem mass spectrometry analysis. Eventually, the assay was validated for qualitative purposes and proved to be specific, sensitive (limit of detection, 10 ng/mL) and precise (relative standard deviations below 18%), demonstrating the general suitability of DBS analysis in sports drug testing also for (pegylated) peptides.

Detection of peginesatide in equine serum using liquid chromatography-tandem mass spectrometry for doping control purposes.

Erythropoietin (EPO) and its recombinant analogues are suspected to be illicitly administered to horses for performance enhancing purposes and, consequently, prohibited in equine sports. Recently, a new erythropoiesis-stimulating agent, peginesatide (Omontys, formerly referred to as Hematide), belonging to the upcoming class of EPO-mimetic peptides, received approval for the treatment of anaemia in humans with chronic kidney disease on dialysis. As the pegylated dimeric peptide of approximately 45 kDa without sequence homology to EPO is not detectable by conventional EPO detection assays, specific methods are bound to be established for horse sports drug testing. Thus, by fortifying equine serum with peginesatide, an approach consisting of a proteolytic digestion with subtilisin after protein precipitation was developed, eventually targeting a proteotypic and xenobiotic pentapeptide which is easily accessible to liquid chromatography- tandem mass spectrometry analysis. The method was validated for qualitative purposes and demonstrated to be specific, precise (relative standard deviations below 14%), sensitive (limit of detection 10 ng mL(-1)) and linear. Being simple, cost-effective and readily transferable to other doping control laboratories, a mass spectrometric assay for the detection of therapeutic concentrations of peginesatide in equine serum is, in terms of preventive doping research, applicable to routine analysis shortly after approval of the drug.

Synthesis, characterisation, and mass spectrometric detection of a pegylated EPO-mimetic peptide for sports drug testing purposes.

Erythropoietin (EPO) and other erythropoiesis-stimulating agents possess a high misuse potential in elite sport due to their ability to increase the oxygen transport capacity, which plays a vital role in enhancing endurance performance. Currently, a new generation of EPO-mimetic peptides is under development from which peginesatide (also referred to as Hematide™), a pegylated homodimeric peptide of approximately 45 kDa with no structural relationship to erythropoietin, is the most advanced drug candidate undergoing phase-III clinical trials. Since preventive doping research aims at the development of detection methods before a drug receives clinical approval, a selective and sensitive assay has to be established knowing that conventional doping control assays for EPO will not succeed in detecting peginesatide. Thus, a pegylated EPO-mimetic peptide simulating the structure and properties of the lead drug candidate peginesatide was synthesised as a model compound for this new class of emerging drugs and characterised by means of gel electrophoresis, matrix-assisted laser desorption/ionisation (MALDI) mass spectrometry, as well as liquid chromatography/electrospray ionisation tandem mass spectrometry (LC/ESI-MS/MS) after proteolytic digestion. Based on these results, a mass spectrometric detection method of the product in plasma was developed targeting a pentapeptide fragment after protein precipitation and subtilisin digestion. Its fitness for purpose was evaluated by the determination of selected method characteristics focusing particularly on specificity, recovery (ca. 60%), and limit of detection (1 ng/mL).

Mass spectrometric characterization of urinary metabolites of the selective androgen receptor modulator S-22 to identify potential targets for routine doping controls.

Drugs that promote anabolic processes with limited undesirable effects are of considerable therapeutic interest; some notable examples include those for the treatment of cancer cachexia and muscle-wasting diseases. Anabolic properties are not only therapeutically beneficial to critically ill and debilitated patients, but are also desirable to athletes seeking artificial enhancements in endurance, strength and accelerated recovery. The use of anabolic agents in the clinical setting is being reconsidered with the emergence of a new class of drugs referred to as SARMs (selective androgen receptor modulators). SARMs have the potential to complement or even replace anabolic androgenic steroidal use with the benefit of a reduction of the undesirable side effects associated with steroid administration alone. Arylpropionamide-based SARMs such as andarine (S-4) and S-22 have shown promising therapeutic properties and have attracted the interest of elite and amateur athletes despite the absence of clinical approval, and evidence for trafficking and misuse in sport has been obtained by doping control authorities. In this communication, the elucidation of urinary metabolites of the SARM drug candidate S-22 is compared with earlier in vitro metabolism studies. Following oral administration of illicit S-22, urine samples were collected after 62 and 135 h and analyzed for the active drug and its major metabolic products. Liquid chromatography interfaced with high-resolution/high-accuracy (tandem) mass spectrometry was used to identify and/or confirm the predicted target analytes for sports drug testing purposes. S-22 was detected in both specimens accompanied by its glucuronic acid conjugate. This was the B-ring hydroxylated derivative of S-22 plus the corresponding glucuronide (with the phase-II metabolites being the more abundant analytes). In addition, the samples collected 62 h post-administration also contained the phase-I metabolite hydroxylated at the methyl residue (C-20) and the B-ring depleted degradation product ('dephenylated' S-22) together with the corresponding carboxy analog that was previously reported for canine metabolism. The obtained data supports future efforts to effectively screen for and confirm the misuse of the non-approved S-22 drug candidate in doping controls.

Structure characterisation of urinary metabolites of the cannabimimetic JWH-018 using chemically synthesised reference material for the support of LC-MS/MS-based drug testing.

As recently reported, the synthetic cannabinoid JWH-018 is the subject of extensive phase I and II metabolic reactions in vivo. Since these studies were based on LC-MS/MS and/or GC-MS identification and characterisation of analytes, the explicit structural assignment of the metabolites was only of preliminary nature, if possible at all. Here, we report the chemical synthesis of five potential in vivo metabolites of JWH-018 derivatives featuring an alkylcarboxy (M1), a terminal alkylhydroxy (M2), a 5-indolehydroxy (M3), an N-dealkylated 5-indolehydroxy (M4) and a 2'-naphthylhydroxy (5) analogue, respectively, and their characterisation by nuclear magnetic resonance spectroscopy. The collision-induced dissociation (CID) patterns of the protonated compounds were studied by high-resolution/high-accuracy tandem mass spectrometry (MS( n )) applying an LTQ Orbitrap with direct infusion and electrospray ionisation of target analytes. An unusual dissociation behaviour including a reversible ion-molecule reaction between a naphthalene cation (m/z 127) and water in the gas phase of the MS was shown to be responsible for nominal neutral losses of 10 u in the course of the CID pathway. LC-MS/MS-supported comparison of synthesised reference standards with an authentic urine sample using an API 4000 QTrap mass spectrometer identified the synthetic JWH-018 analogues M1-M4 as true in vivo metabolites, presuming a chromatographic separation of potentially present regioisomeric analogues. Existing doping control methods were expanded and validated according to international guidelines in order to allow for the detection of the carboxy and the alkylhydroxy metabolites, respectively, as urinary markers for the illegal intake of the synthetic cannabinoid JWH-018. Both metabolites were quantified in authentic doping control urine samples that had been suspicious of JWH-018 abuse after routine screening procedures, and a stable isotope-labelled (13)C(8)-(15)N-carboxy metabolite was synthesised for future analytical applications.

In vitro phase I metabolism of the synthetic cannabimimetic JWH-018.

A potent synthetic cannabinoid receptor agonist, JHW-018, was recently detected as one of the most prominent active agents in abusively used incenses such as Spice and other herbal blends. The high pharmacological and addictive potency of JWH-018 highlights the importance of elucidating the metabolism of JWH-018, without which a meaningful insight into its pharmacokinetics and its toxicity would not be possible. In the present study, the cytochrome P450 phase I metabolites of JWH-018 were investigated, after in vitro incubation of the drug with human liver microsomes, followed by liquid chromatography-tandem mass spectrometry analysis. This revealed monohydroxylation of the naphthalene ring system, the indole moiety, and the alkyl side chain. In addition, observations were made of dihydroxylation of the naphthalene ring system, and the indole moiety, or as result of a combination of monohydroxylations of both the naphthalene ring system and the indole moiety or the alkyl side chain, or a combination of monohydroxylations of both the indole ring system and the alkyl side chain. There is also evidence of trihydroxylation at different locations of the hydroxyl groups in the molecule. Furthermore, dehydration of the alkyl side chain, in combination with both monohydroxylation and dihydroxylation as well as arene oxidation of the naphthalene ring system, combined with both monohydroxylation and dihydroxylation at different sites of oxidation were found. N-dealkylation also in combination with both monohydroxylation and dihydrodiol formation of the N-dealkylated metabolite was detected. Finally, a metabolite was found carboxylated at the alkyl side chain.

Characterization of two major urinary metabolites of the PPARdelta-agonist GW1516 and implementation of the drug in routine doping controls.

Since January 2009, the list of prohibited substances and methods of doping as established by the World Anti-Doping Agency includes new therapeutics such as the peroxisome-proliferator-activated receptor (PPAR)-delta agonist GW1516, which is categorized as a gene doping substance. GW1516 has completed phase II and IV clinical trials regarding dyslipidemia and the regulation of the lipoprotein transport in metabolic syndrome conditions; however, its potential to also improve athletic performance due to the upregulation of genes associated with oxidative metabolism and a modified substrate preference that shifted from carbohydrate to lipid consumption has led to a ban of this compound in elite sport. In a recent report, two presumably mono-oxygenated and bisoxygenated urinary metabolites of GW1516 were presented, which could serve as target analytes for doping control purposes after full characterization. Hence, in the present study, phase I metabolism was simulated by in vitro assays employing human liver microsomal fractions yielding the same oxygenation products, followed by chemical synthesis of the assumed structures of the two abundant metabolic reaction products. These allowed the identification and characterization of mono-oxygenated and bisoxygenated metabolites (sulfoxide and sulfone, respectively) as supported by high-resolution/high-accuracy mass spectrometry with higher-energy collision-induced dissociation, tandem mass spectrometry, and nuclear magnetic resonance spectroscopy. Since urine samples have been the preferred matrix for doping control purposes, a method to detect the new target GW1516 in sports drug testing samples was developed in accordance to conventional screening procedures based on enzymatic hydrolysis and liquid-liquid extraction followed by liquid chromatography, electrospray ionization, and tandem mass spectrometry. Validation was performed for specificity, limit of detection (0.1 ng/ml), recovery (72%), intraday and interday precisions (7.7-15.1%), and ion suppression/enhancement effects (<10%).

Mass spectrometry-based characterization of new drugs and methods of performance manipulation in doping control analysis.

Efficient and comprehensive sports drug testing necessitates frequent updating and proactive, preventive anti-doping research, and the early implementation of new, emerging drugs into routine doping controls is an essential aspect. Several new drugs and drug candidates with potential for abuse, including so-called Rycals (ryanodine receptor calstabin complex stabilizers, for example, S-107), hypoxia-inducible factor (HIF) stabilizers, and peroxisome-proliferator-activated receptor (PPAR) delta agonists (for example, GW1516), were studied using different mass spectrometry- and ion mobility-based approaches, and their gas phase dissociation behaviors were elucidated. The detailed knowledge of fragmentation routes allows a more rapid identification of metabolites and structurally related, presumably "tailor-made", analogs potentially designed for doping purposes. The utility of product ion characterization is demonstrated in particular with GW1516, for which oxidation products were readily identified in urine samples by means of diagnostic fragment ions as measured using high resolution/high accuracy mass spectrometry and higher energy collision-induced dissociation (HCD).

Quantification of electrochemically generated iodine-containing metabolites using inductively coupled plasma mass spectrometry.

For the risk assessment of drug candidates, the identification and quantification of their metabolites is required. The majority of analytical techniques is based on calibration standards for quantification of the metabolites. As these often are not readily available, the use of inductively coupled plasma mass spectrometry (ICPMS) is an attractive alternative for drugs containing heteroatoms. In this work, the online coupling of electrochemistry (EC), liquid chromatography (LC), and ICPMS is presented. The antiarrhythmic agent amiodarone, which contains two iodine atoms, is oxidized in an electrochemical flow-through cell under N-dealkylation and deiodination. The metabolites that are generated at different EC potentials are identified by electrospray ionization (ESI) mass spectrometry, compared to those from rat liver microsomal incubations and quantified by ICPMS. Phase-optimized LC, a recent approach for high-performance isocratic separations, is used to avoid the ICPMS calibration problems known to occur with gradient separations. The potential of the complementary use of ESI-MS and ICPMS for the qualitative and quantitative analysis of drug metabolites becomes apparent in this work.

Synthesis, mass spectrometric characterization, and analysis of the PPARδ agonist GW1516 and its major human metabolites: targets in sports drug testing.

The elucidation of metabolic pathways and the detection of emerging therapeutics potentially enhancing athletic performance are of paramount importance to doping control authorities to protect the integrity of elite sports. A new drug candidate belonging to the family of the peroxisome proliferator-activated receptor-delta agonists termed GW1516 (also referred to as GW501516) has been prohibited by the World Anti-Doping Agency in 2009 due to its potential to artificially increase endurance. Consequently, sports drug testing laboratories need to establish detection methods enabling the identification of the intact substance and/or its metabolite(s) that unambiguously prove the presence or absence of the target substances in doping control specimens. Simulating human metabolic reactions using liver microsomal preparations, minute amounts of possible urinary metabolites were obtained that were characterized by mass spectrometry-based methods. Subsequently, the most abundant metabolic products were chemically synthesized and as well characterized by mass spectrometry and nuclear magnetic resonance spectroscopy. Finally, GW1516 and two oxidized metabolites were implemented in a routine doping control analytical assay based on liquid chromatography-(tandem) mass spectrometry (LC-MS/MS), which was tested for its -fitness-for-purpose using spiked urine samples.

Mass spectrometric detection of peginesatide in human urine in doping control analysis.

Erythropoiesis-stimulating agents (ESAs) have frequently been confessed to be illicitly used in elite sports due to their endurance enhancing effects. Recently, peginesatide, the first representative of a new generation of ESAs, referred to as Erythropoietin (EPO)-mimetic peptides, obtained approval in the USA under the trade name Omontys(®) for the treatment of anaemic patients. Lacking sequence homology with EPO, it consists of a pegylated homodimeric peptide of approximately 45 kDa, and thus, specific approaches for the determination of peginesatide in blood were developed as conventional detection assays for EPO do not allow for the analysis of the EPO-mimetic peptides. However, as urine specimens are the most frequently provided doping control samples and pharmacokinetic studies conducted in rats and monkeys revealed the excretion of the pegylated peptide into urine, a detection method for peginesatide in urine would be desirable. A mass spectrometric assay in human urine was developed consisting of protein precipitation with acetonitrile followed by proteolytic digestion after the removal of the acetonitrile fraction under reduced pressure. Purification and concentration of the resulting proteotypic target peptide was accomplished by means of solid-phase extraction on strong cation-exchange resin prior to liquid chromatographic-tandem mass spectrometric analysis. Method validation was performed for qualitative purposes and demonstrated specificity, precision, linearity as well as sufficient sensitivity (limit of detection: 0.5 ng/ml) while proof-of-concept for the applicability of the assay for the determination of peginesatide in authentic urine samples was obtained by analyzing animal in vivo specimens collected after a single i.v. administration of peginesatide over a period of 4 days.

Screening for the synthetic cannabinoid JWH-018 and its major metabolites in human doping controls.

Referred to as 'spice', several new drugs, advertised as herbal blends, have appeared on the market in the last few years, in which the synthetic cannabinoids JWH-018 and a C(8) homologue of CP 47,497 were identified as major active ingredients. Due to their reported cannabis-like effects, many European countries have banned these substances. The World Anti-Doping Agency has also explicitly prohibited synthetic cannabinoids in elite sport in-competition. Since urine specimens have been the preferred doping control samples, the elucidation of the metabolic pathways of these substances is of particular importance to implement them in sports drug testing programmes. In a recent report, an in vitro phase-I metabolism study of JWH-018 was presented yielding mainly hydroxylated and N-dealkylated metabolites. Due to these findings, a urine sample of a healthy man declaring to have smoked a 'spice' product was screened for potential phase-I and -II metabolites by high-resolution/high-accuracy mass spectrometry in the present report. The majority of the phase-I metabolites observed in earlier in vitro studies of JWH-018 were detected in this urine specimen and furthermore most of their respective monoglucuronides. As no intact JWH-018 was detectable, the monohydroxylated metabolite being the most abundant one was chosen as a target analyte for sports drug testing purposes; a detection method was subsequently developed and validated in accordance to conventional screening protocols based on enzymatic hydrolysis, liquid-liquid extraction, and liquid chromatography/electrospray tandem mass spectrometry analysis. The method was applied to approximately 7500 urine doping control samples yielding two JWH-018 findings and demonstrated its capability for a sensitive and selective identification of JWH-018 and its metabolites in human urine.

[Influence of hospital type on treatment and prognosis in patients with non-ST elevation acute coronary syndrome]. / Impacto del tipo de hospital en el tratamiento y evolución de los pacientes con síndrome coronario agudo sin elevación del ST.

INTRODUCTION AND OBJECTIVES: Clinical practice guidelines on non-ST-segment elevation acute coronary syndrome (NSTEACS) do not take either hospital infrastructure or the availability of a catheterization laboratory into account. The aim of this study was to determine the influence of hospital type, either with or without a catheterization laboratory, on treatment and medium-term prognosis in patients with NSTEACS. METHODS: The GYSCA multicenter study (covering 15 hospitals) investigated the implementation of clinical practice guidelines in patients with NSTEACS at six hospitals with catheterization laboratories (i.e. tertiary-care hospitals; THs) and nine without (i.e. secondary-care hospitals; SHs). Patients were assessed clinically at hospital discharge and after 3 and 12 months. RESULTS: In total, 1133 consecutive patients were recruited: 599 (52.9%) in THs and 534 (47.1%) in SHs. The use of specific class-I interventions (i.e. aspirin, clopidogrel, beta-blockers, angiotensin-converting enzyme inhibitors and statins) was more common in THs (P< .01) and more patients in THs underwent revascularization while in hospital (43% vs. 30%; P< .01). The number of SH patients who were readmitted for NSTEACS at 1 year was 5-fold greater than the number of TH patients (12.8% vs. 2.3%; P< .01), and hospital type was a predictor of an adverse event. CONCLUSIONS: Patients admitted for NSTEACS to a hospital without a catheterization laboratory were managed less invasively and their drug treatment was less likely to have been modified to match guideline recommendations. In addition to other well-known prognostic factors, hospital type can also have an influence on patient outcomes.

Speciation analysis of gadolinium chelates in hospital effluents and wastewater treatment plant sewage by a novel HILIC/ICP-MS method.

The behavior of Gd chelates used in magnetic resonance imaging (MRI) within the process of sewage treatment is widely unknown. Due to the varying toxicity of the particular Gd species [J. M. Idee et al. Fundam. Clin. Pharmacol. 2006, 20, 563-576], it is important to not only investigate total Gd concentrations, but the Gd species as well. This work describes a novel method for speciation analysis of the most important gadolinium chelates in wastewaters. This novel approach consists of coupling hydrophilic interaction chromatography (HILIC) with inductively coupled plasma mass spectrometry (ICP-MS). HILIC/ICP-MS exhibits high separation efficiency for the simultaneous separation of the five predominantly applied MRI contrast agents and the required selectivity and sensitivity for trace determination in wastewater samples. For the first time, the distribution of particular Gd chelate complexes was determined in hospital effluent, municipal sewage, and wastewater treatment plant (WWTP) samples. The data were compared with the total concentration of Gd as determined by ICP-MS. The active compounds of Multihance, Dotarem, and Gadovist were identified in local WWTP samples. Interestingly, the macrocyclic, nonionic compound Gd-BT-DO3A (Gadovist) was found to be the most abundant Gd complex in all investigated samples. This is in contrast to prevalent assumptions that linear ionic Gd chelates such as Gd-DTPA (Magnevist) would be the predominant species [G. Morteani et al. Environ. Geochem. Health 2006, 28, 257-264 and M. Bau and P. Dulski, Earth Planet. Sci. Lett. 1996, 143, 245-255]. Although contrast agent concentrations tend to be reduced during wastewater treatment, Gd-BT-DO3A was still found in WWTP effluents.

Dendritic cell maturation with poly(I:C)-based versus PGE2-based cytokine combinations results in differential functional characteristics relevant to clinical application.

In vitro maturation of dendritic cells (DCs) for cancer immunotherapy may be accomplished by cytokine cocktails containing prostaglandin E2 (PGE2). More recently, a poly(I:C)-based protocol has been proposed as a potentially superior alternative because of a strong induction of interleukin (IL)-12 secretion by resulting DCs. As optimal DC maturation represents a crucial issue for cancer vaccination trials, we performed a systematic and comprehensive comparison of both protocols with respect to important indicators of DC function. Although both methods yielded phenotypically mature DCs, transcriptional profiling revealed a substantially higher number of differentially regulated genes after poly(I:C)-based than PGE2-based maturation. Several of these are involved in immunologic processes, indicating that both DC types exhibit subtle, but distinct, molecular properties. Up-regulation of genes encoding the T-cell-attracting chemokines CXCL9, 10, and 11 in poly(I:C)-DC but not PGE2-DC was confirmed on a protein level. Although poly(I:C)-based maturation induced substantial IL-12p70 secretion, poly(I:C)-DC also secreted low levels of IL-10 and showed a significantly higher expression of functionally active indoleamine-2,3-dioxygenase than PGE2-DC, which might mediate immune inhibitory functions. Nonetheless, the number of peptide-specific T cells tended to be higher after in vitro priming with poly(I:C)-DC compared with PGE2-DC. Finally, PGE2-DC displayed superior migratory abilities, which are essential for in vivo applications. In summary, we have identified previously unrecognized shared and distinct molecular features of DCs matured by 2 commonly used protocols that lead to subtle, but significant, immunologic features of the resulting cells relevant to clinical applications.

Impacto del tipo de hospital en el tratamiento y evolución de los pacientes con síndrome coronario agudo sin elevación del ST / Influence of hospital type on treatment and prognosis in patients with non-ST elevation acute coronary syndrome

Introducción y objetivos. Las guías de práctica clínica del síndrome coronario agudo sin elevación del ST (SCASEST) no valoran la infraestructura hospitalaria y la facilidad de acceso a la sala de hemodinámica. Este estudio analiza la influencia del tipo de hospital, con o sin sala de hemodinámica, en la forma de tratamiento de pacientes con SCASEST y su posible impacto en el pronóstico a medio plazo. Métodos. El GYSCA es un registro multicéntrico (15 hospitales) que analiza la aplicación de las guías en pacientes con SCASEST: 6 con sala de hemodinámica (hospitales centrales) y 9 sin hemodinámica (hospitales comarcales). Se realizó seguimiento clínico al alta y a los 3 y a los 12 meses. Resultados. Se reclutó a 1.133 pacientes consecutivos; 599 (52,9%) en hospitales centrales y 534 (47,1%) en hospitales comarcales. El uso de intervenciones de clase I fue mayor en los centrales (aspirina, clopidogrel, bloqueadores beta, IECA y estatinas; p < 0,01) y se revascularizó a más pacientes durante la hospitalización (el 43 frente al 30%; p < 0,01). El número de pacientes de hospitales comarcales que reingresaron por SCASEST al año fue 5 veces mayor que en los centrales (el 12,8 frente al 2,3%; p < 0,01), y el tipo de hospital fue uno de los predictores de eventos. Conclusiones. Los pacientes que ingresan por SCASEST en hospitales que no disponen de sala de hemodinámica son tratados de forma menos invasiva y con un tratamiento farmacológico menos ajustado a lo recomendado en las guías. Junto con los conocidos factores predictivos del pronóstico, el tipo de hospital puede tener un impacto adicional en la evolución (AU)

Introduction and objectives. Clinical practice guidelines on non-ST-segment elevation acute coronary syndrome (NSTEACS) do not take either hospital infrastructure or the availability of a catheterization laboratory into account. The aim of this study was to determine the influence of hospital type, either with or without a catheterization laboratory, on treatment and medium-term prognosis in patients with NSTEACS. Methods. The GYSCA multicenter study (covering 15 hospitals) investigated the implementation of clinical practice guidelines in patients with NSTEACS at six hospitals with catheterization laboratories (i.e. tertiary-care hospitals; THs) and nine without (i.e. secondary-care hospitals; SHs). Patients were assessed clinically at hospital discharge and after 3 and 12 months. Results. In total, 1133 consecutive patients were recruited: 599 (52.9%) in THs and 534 (47.1%) in SHs. The use of specific class-I interventions (i.e. aspirin, clopidogrel, beta-blockers, angiotensin-converting enzyme inhibitors and statins) was more common in THs (P < .01) and more patients in THs underwent revascularization while in hospital (43% vs. 30%; P < .01). The number of SH patients who were readmitted for NSTEACS at 1 year was 5-fold greater than the number of TH patients (12.8% vs. 2.3%; P < .01), and hospital type was a predictor of an adverse event. Conclusions. Patients admitted for NSTEACS to a hospital without a catheterization laboratory were managed less invasively and their drug treatment was less likely to have been modified to match guideline recommendations. In addition to other well-known prognostic factors, hospital type can also have an influence on patient outcomes (AU)