Establishing Syndromic Surveillance of Acute Coronary Syndrome, Myocardial Infarction, and Stroke: Registry Study Based on Routine Data From German Emergency Departments

Abstract

Background: Emergency department (ED) routine data offer a unique opportunity for syndromic surveillance of communicable and noncommunicable diseases (NCDs). In 2020, the Robert Koch Institute established a syndromic surveillance system using ED data from the AKTIN registry. The system provides daily insights into ED utilization for infectious diseases. Adding NCD indicators to the surveillance is of great public health importance, especially during acute events, where timely monitoring enables targeted public health responses and communication.

Objective: This study aimed to develop and validate syndrome definitions for the NCD indicators of acute coronary syndrome (ACS), myocardial infarction (MI), and stroke (STR).

Methods: First, syndrome definitions were developed with clinical experts combining ED diagnosis, chief complaints, diagnostic certainty, and discharge information. Then, using the multicenter retrospective routine ED data provided by the AKTIN registry, we conducted internal validation by linking ED cases fulfilling the syndrome definition with the hospital discharge diagnoses and calculating sensitivity, specificity, and accuracy. Lastly, external validation comprised the comparison of the ED cases fulfilling the syndrome definition with the federal German hospital diagnosis statistic. Ratios comparing the relative number of cases for all syndrome definitions were calculated and stratified by age and sex.

Results: We analyzed data from 9 EDs, totaling 704,797 attendances from January 1, 2019, to March 5, 2021. Syndrome definitions were based on ICD-10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision-German Modification) diagnoses, chief complaints, and discharge information. We identified 4.3% of all cases as ACS, 0.6% as MI, and 3.2% as STR. Patients with ACS and MI were more likely to be male (58.3% and 64.7%), compared to the overall attendances (52.7%). For all syndrome definitions, the prevalence was higher in the older age groups (60-79 years and >80 years), and the highest proportions of cases were assigned an urgency level (3=urgent or 2=very urgent). The internal validation showed accuracy and specificity levels above 96% for all syndrome definitions. The sensitivity was 85.3% for ACS, 56.6% for MI, and 80.5% for STR. The external validation showed high levels of correspondence between the ED data and the German hospital statistics, with most ratios ranging around 1, indicating congruence, particularly in older age groups. The highest differences were noted in younger age groups, with the highest ratios in women aged between 20 and 39 years (4.57 for MI and 4.17 for ACS).

Conclusions: We developed NCD indicators for ACS, MI, and STR that showed high levels of internal and external validity. The integration of these indicators into the syndromic surveillance system for EDs could enable daily monitoring of NCD patterns and trends to enhance timely public health surveillance in Germany.

Keywords: Germany; accuracy; acute coronary syndrome; diagnosis; emergency department; emergency medicine; health surveillance; myocardial infarction; public health; public health surveillance; routine data; routinely collected health data; stroke; syndrome; syndromic surveillance.

Figure 1.. Final syndrome definition for acute coronary syndrome (ACS). ED: emergency department.

Figure 2.. Final syndrome definition for myocardial infarction (MI). ED: emergency department.

Figure 3.. Final syndrome definition for stroke (STR). ED: emergency department; CEDIS-PCL: Canadian Emergency Department Information System–Presenting Complaint List; CVA: cerebrovascular accident.

Figure 4.. Time series showing a 7-day-moving average of the absolute number of cases of acute coronary syndrome (ACS), myocardial infarction (MI), and stroke (STR) identified in emergency department (ED) data (red, left y-axis) compared to inpatient care data (blue, right y-axis); Note: y-axes are not equal.

Figure 5.. Ratios and 95% CIs calculated based on the comparison of age and sex stratified relative numbers of emergency department (ED) cases of acute coronary syndrome (ACS), myocardial infarction (MI), and stroke (STR) with data from the hospital diagnosis statistic.