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Original Investigation
August 7, 2019

Assessment of the German and Italian Stress Cardiomyopathy Score for Risk Stratification for In-hospital Complications in Patients With Takotsubo Syndrome

Author Affiliations
  • 1Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
  • 2Interventional Cardiology, Cardiovascular Institute, Hospital Clínico Universitario San Carlos, Madrid, Spain
  • 3Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Heart Center Lübeck, Lübeck, Germany
  • 4German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
  • 5First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
  • 6German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg-Mannheim, Mannheim, Germany
  • 7Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital, Umberto I–Lancisi–Salesi, Ancona, Italy
  • 8Biomedical Department of Internal Medicine and Medical Specialties, Cardiology Unit, University of Palermo, Palermo, Italy
  • 9Division of Cardiology, University of Rome Tor Vergata, Rome, Italy
  • 10Department of Cardiology, Asklepios Klinik–St Georg, Hamburg, Germany
  • 11Department of Cardiology, Bonomo Hospital, Andria, Italy
  • 12Department of Cardiology, San Paolo Hospital, Bari, Italy
  • 13Department of Cardiology, San Giovanni di Dio Hospital, University of Cagliari, Cagliari, Italy
  • 14Department of Internal Medicine and Cardiology, Heart Center Leipzig–University Hospital, Leipzig, Germany
  • 15Gruppo Villa Maria Care and Research, Santa Maria Hospital, Bari, Italy
  • 16Servicio de Cardiología, Hospital Virgen de la Macarena, Sevilla, Spain
  • 17Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital de Sant Pau, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Barcelona, Spain
JAMA Cardiol. Published online August 7, 2019. doi:10.1001/jamacardio.2019.2597
Key Points

Question  Which patients with takotsubo syndrome should be considered at high risk for in-hospital complications?

Findings  In this multicenter prognostic study of 1007 patients from the German and Italian Stress Cardiomyopathy (GEIST) registry and 946 patients from the Spanish Registry for Takotsubo Cardiomyopathy (for external validation), male sex, history of neurologic disorder, right ventricular involvement, and left ventricular ejection fraction were identified as predictors of in-hospital complications using the GEIST score, a score for prediction of in-hospital complications.

Meaning  The findings suggest that evaluation of 4 clinical and echocardiographic variables may identify patients with takotsubo syndrome who have a high risk for in-hospital complications.


Importance  Takotsubo syndrome (TTS) is an acute, reversible heart failure syndrome featured by significant rates of in-hospital complications. There is a lack of data for risk stratification during hospitalization.

Objective  To derive a simple clinical score for risk prediction of in-hospital complications among patients with TTS.

Design, Setting, and Participants  In this prognostic study, 1007 consecutive patients were enrolled in the German and Italian Stress Cardiomyopathy (GEIST) registry from July 1, 2007, through December 31, 2017, and identified as the derivation cohort; 946 patients were enrolled in the Spanish Registry for Takotsubo Cardiomyopathy (RETAKO) as the external score validation. An admission risk score was developed using a stepwise multivariable regression analysis from 2 registries. Data analysis was performed from March 1, 2018, through July 31, 2018.

Main Outcomes and Measures  In-hospital complications were defined as death, pulmonary edema, need for invasive ventilation, and cardiogenic shock. Four variables were identified as independent predictors of in-hospital complications and were used for the score: male sex, history of neurologic disorder, right ventricular involvement, and left ventricular ejection fraction (LVEF).

Results  Of the 1007 patients enrolled in the GEIST registry, 107 (10.6%) were male, with mean (SD) age of 69.8 (11.4) years. Overall rate of in-hospital complications was 23.3% (235 of 1007) (death, 4.0%; pulmonary edema, 5.8%; invasive ventilation, 6.4%; and cardiogenic shock, 9.1%). The GEIST prognosis score was derived by providing 20 points each for male sex and history of neurologic disorders and 30 points for right ventricular involvement and then subtracting the value in percent of LVEF (decimal values between 0.15 and 0.70). Score accuracy on area under the receiver operating characteristic curve analysis was 0.71, with a negative predictive power of 87% with scores less than 20. External validation in the RETAKO population (124 [13.1%] male; mean [SD] age, 69.5 [14.9] years) revealed an area under the curve of 0.73 (P = .46 vs GEIST derivation cohort). Stratification into 3 risk groups (<20, 20-40, and >40 points) classified 316 patients (40.9%) as having low risk; 342 (44.3%) as having intermediate risk, and 114 (14.8%) as having high risk of complications. The observed in-hospital complication rates were 12.7% for low-risk patients, 23.4% for intermediate-risk patients, and 58.8% for high-risk patients (P < .001 for trend). After 2.6 years of follow-up, patients with in-hospital complications had significantly higher rates of mortality than those without complications (40% vs 10%, P = .01).

Conclusions and Relevance  The GEIST prognostic score may be useful in early risk stratification for TTS. High-risk patients with TTS may require an intensive care unit stay, and low-risk patients with TTS could be discharged within a few days. In-hospital complications in patients with TTS may be associated with increased risk of long-term mortality.