Cardiac Beat Annotation Codes

     
MADAE Code # Description Definition
C1 Normal beat NEW Definition. Will be PPT/Video with animation and sound
C2 Left bundle branch block beat See attached definition for LBBB
C3 Right bundle branch block beat See attached definition for RBBB
C4 Bundle branch block beat (unspecified) See attached definition for UNSPECIFIED BBB
C5 Atrial premature beat Beats originating from ectopic pacemaking tissue within the atria. There is an abnormal P wave, usually followed by a normal QRS pattern occurring singly, preceded and followed by at least one normal sinus beats; i.e. "NAN" where N=Normal Sinus and A=APB
C6 Aberrantly conducted Supraventricular ectopic beat (includes Atrial/Nodal/Junctional Beats)
An SVEB with a QRS configuration different or altered from the Normal Sinus QRS, usually seen with a widened or bizarre QRS configuration due to the SVEB impulse propagation through the ventricles during the partial refractory phase. Hence, a QRS configuration similar to that of a VEB. SVEB's with aberrant ventricular conduction are generally recognizable when the ectopic P-wave precedes the QRS complex. In all other cases, the presence of Ashman's phenomenon or the concurrent display of a Normal QRS configuration on another recorded channel will be utilized in determining this classification.
C7 Nodal (junctional) premature beat
These beats originate from within the region of the AV node, resulting in an absence of p-waves, or abnormal p-waves with PR intervals of <.12 secs. (these retrograde p-waves are typically inverted in leads II, III, and AVF). Ventricular conduction is usually normal resulting in a normal QRS. These beats are followed by a compensatory pause
C8 Supraventricular ectopic beat (includes Atrial/Nodal/Junctional Beats)  
C9 Premature ventricular contraction  VEBS (includes C25-C27) Recordings contain VEB's that are of the same form. This definition is based on shape alone; coup ling intervals are not used to discriminate forms. Fusion beats are excluded when determining VEB form.
  Isolated Multiform VEB‘s Recordings containing VEB's of different forms This definition is based upon shape. Coupling intervals are not used to define forms. Fusion beats are excluded when determining VEB form.
C10 R-on-T premature ventricular contraction Recordings containing VEB's are included in this class only if the VEB's are preceded by complexes of nonventricular origin. The onset of these early isolated VEB's must be clearly within the T-wave of the complex.
C11 Fusion of ventricular and normal beat Isolated VEBs which usually occur without any compensatory pause, and do not significantly alter the concurrent heart rate. The QRS configuration contains characteristics of both the normal sinus beet and the VEB, and is usually preceded by a P-wave.
C12 Atrial escape beat
When sinus node fails to produce an impulse, another focus within the atrium takes over the duty. An atrial escape beat occurs after a prolonged pause resulting from SA exit block or sinus arrest. 3 or more atrial escape beats occurring consecutively at a rate above 60 bpm is atrial escape rhythm.
C13 Nodal (junctional) escape beat
When the rate of depolarization of the sinoatrial node falls below the rate of the atrioventricular node, a depolarization from somewhere in the AV node will occur; either as a single escape beat, or as a series of escape beats (escape rhythm). P-wave morphology depends on the site of the ectopic focus, will be inverted; and may appear before, during, or after the QRS complex. If the P-wave occurs before the QRS complex, the PR interval will be less than 0.12 seconds. The QRS complex will usually be normal in duration and morphology.
C14 Supraventricular escape beat (Supraventricular but not clearly Atrial/Nodal/Junctional) When the sinus node fails to produce an impulse, another supraventricular focus takes over depolarization either as a single escape beat, or as a series of escape beats (escape rhythm).
C15 Ventricular escape beat When the rate of supraventricular impulses arriving at the AV node or ventricle is less than the intrinsic rate of the ectopic pacemaker, a ventricular escape beat may occur. The QRS complexes of a ventricular escape beat are broad (≥ 120 ms) and can have a LBBB or RBBB morphology at a rate of 20-40 bpm.
C16 Paced beat  (includes C21-C24) An pacemaker regulates the timing and sequence of a heart beat when the hearts natural pacemaker is unable to do so. There are a number of pacemaker types which are defined more clearly below in codes R9, C17, and C21-C24.
C17 Fusion of paced and normal beat A pacemaker fusion beat occurs when the intrinsic beat and pacemaker stimulus beat partly depolarize the ventricles, causing a hybrid QRS complex.
C17 Intermittent IVCD/BBB Intermittent or alternating Right Bundle Branch Block or Left Bundle Branch Block with no other Arrhythmias.
C17 Blocked SVEB An ectopic P-wave occurring so soon after a normal sinus beat, that the ventricle is still in a refractory period and will not respond. A less than full compensatory pause will usually occur, and will be less than twice the preceding normal R-R interval.
C17 Isolated SVEB's SVEB's with a normal QRS pattern occurring singly, in no patterns with other ectopic beats, preceded and followed by at least two normal sinus beats; i.e. "NNSNN" where N=Normal Sinus and S=SVEB.
C18 Unclassifiable beat  
C19 Beat not classified during learning  
C20 Interpolated VEBS
An isolated VEB which occurs without any compensatory pause between two normal sinus beats, but significantly alters the concurrent heart rate. The sequence appears as: "N_NVN__N", where N=Nornal Sinus Beat, V=VEB, and _= the regular R-R interval between the Normal Sinus Beats.
C21 Atrial Paced Beat
Atrial pacing will appears on the ECG as a single pacemaker spike followed by a P-wave. The P-wave morphology is entirely dependent upon the location of the atrial lead. The PR interval and the QRS complex are independent of the atrial pacemaker, and are determined by the intrinsic characteristics of the patient's normal conduction system. Pacing is continuous if the rhythm is entirely paced, or intermittent if the atrial pacemaker is in a demand mode.
C22 Ventricular Paced Beat LBB Morphology  
C23 Ventricular Paced Beat RBB Morphology A pacemaker lead wire placed in the left ventricle produces a right bundle branch morphology on the ECG.
C24 Dual Chamber Paced Beat/AV Sequential Paced beat
Uses one lead in the right atrium, and the other in the right ventricle. In AV sequential pacing, pacemaker spikes will occur both before the P wave and the QRS complex. However, no pacemaker spike will occur before the P-wave, if the native atrial rate is faster than the programmed lower rate of the pacemaker. There is either a paced or native QRS depending upon the pacemaker’s programming and AV conduction. If paced, the QRS has a left bundle branch block (LBBB) morphology. If there is a native ventricular depolarization, the QRS morphology is normal (unless a native bundle branch block is present).
C25 VEB Left Bundle Branch Morphology Ventricular Ectopic Beats originating from the right ventricle have a left bundle branch block morphology (dominant S wave in V1).
C26 VEB Right Bundle Branch Morphology Ventricular Ectopic Beats originating from the left ventricle have a right bundle branch block morphology (dominant R wave in V1).
C27 VEB Unspecified Morphology Ventricular Ectopic Beats having neither a right nor left bundle branch block morphology, but still meeting all other specifications for Ventricular Ectopic beats.
C28 A pseudo-beat label generated during a segment marked unreadable An event occuring during an ECG recording segment marked unreadable that is treated by the analysis algorithm as a heart beat of supraventricular or ventricular origin.
C29 A pseudo-beat label generated at any other time An event occuring anytime during an ECG recording (that is NOT marked unreadable) which is treated by the analysis algorithm as a heart beat of supraventricular or ventricular origin.
 
 

Cardiac Rhythm Annotation Codes

     
Code # Description Definition
R1 SVEB Patterns-bigeminy (includes Atrial/Nodal/Junctional Beats)
SVEB's occurring singly but in the following minimum sequence of QRS complexes: "ONSNSO"; where O=Any Other Beat (Normal or Ectopic), N=Normal Sinus Beat, and S=SVEB. Variations in coupling intervals and/or form do not preclude bigeminy.
R2 Atrial fibrillation An irregularly irregular rhythm in which P waves are NOT present. R-R intervals are variable. Absence of a clear isoelectric baseline. QRS complexes are often < 120 ms unless there is a pre-existing bundle branch block, accessory pathway, or rate related aberrant conduction. Fibrillatory “f”waves are often present and can be either fine (amplitude < 0.5mm) or coarse (amplitude >0.5mm). Be aware that coarse “f” waves can sometimes mimic p-waves and be misinterpreted.
R3 Atrial flutter
Is a narrow complex tachycardia with a regular atrial activity at ~300 bpm. Flutter waves (“saw-tooth” pattern) best seen in leads II, III, AVF . Flutter waves in V1 may resemble P waves. Loss of a clear isoelectric baseline. There can be a fixed AV block (e.g. 2:1. 3:1, 4:1, etc). or a variable AV Block (mimicking atrial fibrillation). In atrial flutter with variable block the R-R intervals will be multiples of the P-P interval — e.g. assuming an atrial rate of 300bpm (P-P interval of 200 ms), the R-R interval would be 400 ms with 2:1 block, 600 ms with 3:1 block, and 800 ms with 4:1 block. Look for identical R-R intervals occurring sporadically along the rhythm strip; then look to see whether there is a mathematical relationship between the various R-R intervals on the ECG. In contrast, atrial fibrillation will be completely irregular, with no patterns to be discerned within the R-R intervals.
R4 Ventricular bigeminy VEB's occurring singly but in the following minimum sequence of QRS complexes: "ONVNVO"; where O=Any Other Beat (Normal or Ectopic) , N=Normal Sinus Beat, and V=VEB. Variations in coupling intervals and/or form do not preclude bigeminy.
R5 2° AV block A second degree AV Block in which a singular ventricular beat is dropped in a cyclic fashion. With the first atrial impulse of the cycle, there is usually a normal P-R interval. With each succeeding beat, the P-R interval becomes progressively longer, until after several beats an atrial contraction fails to initiate a ventricular response (which results in a long diastolic pause). The P-P interval remains relatively constant. The RR interval progressively shortens with each beat of the cycle. The number of beats in each cycle is not necessarily constant.
R6 Idioventricular rhythm Idioventricular Rhythm (IVR): Appears as Slow ventricular tachycardia, usually at rates below 60 BPM with all other characteristics of VT (including the presence of atrioventricular dissociation). Accelerated Idioventricular Rhythm (AIVR) exists when the ventricular rate is between 60 and 120 bpm.
R7 Normal sinus rhythm A basic rhythm with normal PQRST intervals/durations. Regular R-R intervals at a rate of 60-100 bpm (subject 6 years of age or older). Each QRS complex is preceded by a normal P-wave. PR interval is normal and remains constant. QRS duration is < 100ms wide.
R8 Nodal (A-V junctional) rhythm
In junctional rhythm, the heart's atrioventricular node takes over as the heart’s pacemaker (typically at rates of 40-60 BPM) The atria will still contract before the ventricles through a backwards or retrograde conduction (conduction comes from the AV node into and through the atria). On the ECG, junctional rhythm usually presents with a missing or inverted P-wave. Retrograde P-waves refers to the depolarization from the AV node back towards the SA node.
R9 Paced rhythm

As a basic definition, Pacemaker Rhythm is the propagation of cardiac depolarization by an implanted electrical device; as well as the interaction of such devices with a patient’s native cardiac conduction system. Atrial and/or ventricular pacing can be detected in an ECG as a pacemaker spike occurring before a P-wave (atrial) or before a QRS (ventricular) or both (Dual chamber). A pacemaker lead wire placed in the right ventricle will produce a left bundle branch block pattern on the ECG. A lead wire in the left ventricle will produce a right bundle branch pattern.

Dual chamber pacemakers use two leads, with one lead in the right atrium and the other in the right ventricle.

Bi-ventricular pacemakers use three leads, one for each ventricle and one for the right atrium; used for cardiac resynchronization therapy to restore synchronous ventricular contractions. 

Fixed rate (Asychronous) pacing occurs at a pre-determined rate regardless of the patient's heart rate.

Demand (Synchronous) pacing occurs only when the patient's heart rate falls below a specific rate.

R10 Wolff-Parkinson-White (WPW)

Wolff-Parkinson-White syndrome is associated with an accessory pathway that bypasses normal conduction through the AV node, bringing about a direct connection between the atrial electrical system and ventricles (resulting in a more rapid depolarization of the ventricles). This “pre-excitation” results in a shortened PR interval, and a slurring of the upstroke of the QRS complex (delta wave) on the ECG. The ability to bypass the AV node, or the establishment of a reentry circuit involving the accessory pathway, can result in the production of paroxysmal tachycardias, often referred to as atrioventricular reentry tachycardias (AVRT). The following definition is taken from the following AHA/ACCF/HRS Expert Consensus Document:
Borys Surawicz MD, FAHA, FACC; Rory Childers MD; Barbara J. Deal MD, FACC; Leonard S. Gettes MD, FAHA, FACC: AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram: Part III: Intraventricular Conduction Disturbances A Scientific Statement From the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society Endorsed by the International Society for Computerized Electrocardiology. Journal of the American College of Cardiology, Volume 53, Issue 11, 17 March 2009, Pages 976-981

Ventricular Preexcitation of Wolff-Parkinson-White Type
Whether preexcitation is full or not cannot be determined from the body surface ECG, but the following criteria are suggestive of full preexcitation:
1. PR interval (assuming no intra-atrial or interatrial conduction block) less than 120 ms during sinus rhythm in adults and less than 90 ms in children.
2. Slurring of initial portion of the QRS complex (delta wave), which either interrupts the P wave or arises immediately after its termination.
3. QRS duration greater than 120 ms in adults and greater than 90 ms in children.
4. Secondary ST and T wave changes.

R11 Sinus bradycardia A basic rhythm with normal PQRST intervals/durations. Regular R-R intervals at a rate of less than 60 bpm (subject 6 years of age or older). Each QRS complex is preceded by a normal P-wave. PR interval is normal and remains constant. QRS duration is < 100ms wide.
R12 Supraventricular tachyarrhythmia Three or more sequential SVEB's preceded and followed by at least one (1) Normal Sinus Beat; i.e., NSSSN, where N=Normal Sinus Beat, and S=SVEB. This class also contains sustained or non-sustained Paroxysmal Atrial Tachycardia and Supraventricular Tachycardia.
R13 Ventricular trigeminy Ventricular Ectopic beats occurring as every third beat. VEB's occurring singly but in the following minimum sequence of QRS complexes: "ONNVNNVO"; where O=Any Other Beat (Normal or Ectopic) , N=Normal Sinus Beat, and V=VEB. Variations in coupling intervals and/or form do not preclude bigeminy.
R14 Ventricular flutter/Ventricular Fibrillation Ventricular Fibrillation: is characterized as a chaotic irregular unformed QRS deflections in the baseline with varying amplitudes in which there are no identifiable P waves, or T waves. Heart rates are usually >500bpm.00
  Ventricular Flutter Ventricular Flutter: is an extreme form of VT often seen at rates > 300 BPM. The QRS complexes shows a typical sinusoidal pattern that looks the same when turned upside down. Ventricular Flutter often degenerates into Ventricular Fibrillation
R15 Ventricular tachycardia  (includes non-sustained and sustained VT, but not Torsades) Non-sustained Ventricular Tachycardia (NSVT): an episode of ventricular tachycardia with a heart rate greater than 120 beats per minute, lasting for at least three beats and terminating spontaneously in < 30 seconds. In Monomorphic VT, all ventricular beats have the same QRS configuration. A right bundle branch block (RBBB) pattern is defined by a mono-, bi-, or triphasic R wave or qR in V1; LBBB pattern is defined by a QS, rS, or qrS in V1. In Polymorphic VT, ventricular beats may have multiple QRS configurations.
  Sustained Ventricular Tachycardia Sustained Ventricular Tachycardia: an episode of ventricular tachycardia with a heart rate of greater than 120 beats per minute, persisting more than 30 seconds. In Monomorphic VT, all ventricular beats have the same QRS configuration. A right bundle branch block (RBBB) pattern is defined by a mono-, bi-, or triphasic R wave or qR in V1; LBBB pattern is defined by a QS, rS, or qrS in V1. In Polymorphic VT, ventricular beats may have multiple QRS configurations.
R16 Torsades De Pointes Torsades dePointes (TdP): Is a form of Polymorphic VT in which the QRS complexes “twist” around the isoelectric line (the morphology of the QRS vector switches from positive to negative and back again).
R17 Marked Sinus Arrhythmia A basic rhythm with normal PQRST intervals/durations. Regular R-R intervals at a rate of 60-100 bpm (subject 6 years of age or older). Each QRS
R18 Sinus Tachycardia (HR ≥ 120 BPM) A basic rhythm with normal PQRST intervals/durations. Regular R-R intervals at a rate of greater than 100 bpm (subject 6 years of age or older). Each QRS complex is preceded by a normal P-wave. PR interval is normal and remains constant. QRS duration is < 100ms wide.
R19 ST Depression (≥ 2mm)
The ST segment starts at the J point (the junction between the end of the QRS and the beginning of the ST segment) and ends at the beginning of the T wave. The normal ST segment is isoelectric; is essentially level with the PR and TP (baseline) segments, and has a duration of 0.080 to 0.120 secs. The shape and direction of the ST segment are the important indicators to measure along with T-wave changes when trying to determine myocardial ischemia/infarction. Significant ST depression or ST Elevation in the Ambulatory ECG (A-ECG) is determined when the ST segment is > 2mm below or above the baseline respectively. When viewing a 12-lead A-ECG, reciprocal changes in the ST segments and T-waves among the leads should be noted.
R20 ST Elevation (≥ 2mm)
The ST segment starts at the J point (the junction between the end of the QRS and the beginning of the ST segment) and ends at the beginning of the T wave. The normal ST segment is isoelectric; is essentially level with the PR and TP (baseline) segments, and has a duration of 0.080 to 0.120 secs. The shape and direction of the ST segment are the important indicators to measure along with T-wave changes when trying to determine myocardial ischemia/infarction. Significant ST depression or ST Elevation in the Ambulatory ECG (A-ECG) is determined when the ST segment is > 2mm below or above the baseline respectively. When viewing a 12-lead A-ECG, reciprocal changes in the ST segments and T-waves among the leads should be noted.
R21 SVEB Couplets Two sequential SVEB's preceded and followed by at least one (1) Normal Sinus Beat; i.e., "NSSN", where N=Normal Sinus Beat, and S=SVEB.
R22 VEB Couplets Two sequential VEB's preceded and followed by at least one (1) Normal Sinus Beat; i.e., "NVVN", where N=Normal Sinus Beat, and V=VEB. For couplet recordings, multiformity is determined by the shape of any isolated VEB's and the shape of the first complex only of any couplets. The form of the second complex is ignored.
  Ventricular Rhythms Three or more sequential VEB's preceded and followed by at least one (1) Normal Sinus Beat; i.e., "NVVVN", where N=Normal Sinus Beat, and V=VEB (regardless of shape and coupling interval). This class can occur at any heart rate.
R23 Sinus Pause/Arrest A pause in the cardiac rhythm due to momentary failure of the sinus node to initiate an impulse. This will result in at least one (1) "dropped beat". The pause between normal conducted beats should be at least twice the immediately preceding P-P interval.
R24 Wandering Atrial Pacemaker A form of multifocal atrial rhythm at a rate of <100bpm. WAP exists when at least 3 ectopic foci in the atrium generate action potentials that result in ventricular conduction. In WAP, each QRS will be preceded by a p-wave (with varying morphologies reflecting varying atrial ectopic foci).
  No VEB's Recordings may not contain Ventricular Arrhythmias, but may contain any other type of arrhythmias. This class is intended to be used to evaluate false positive rates of detectors.
R25 2° SA Block
There are two types of second degree SA block: In Type I (Wenckeback) there is a progressive delay in the conduction from the sinoatrial node to the atrium until one impulse is completely blocked. This is seen in the ECG as a progressively shortening of the PP interval before the dropped P-wave. The PQRS complexes occur in groups, with the dropped P-wave occurring at the end of each group. This is often misinterpreted as sinus arrhythmia. In Type II SA block the pattern of blocked beats is equivalent to Mobitz II (no Wenckeback pattern). There is no clustering of the PQRS complexes, and the pause surrounding the dropped P wave is an exact multiple of the preceding P-P interval.
  Complete AV Dissociation The basic rhythm is AV Nodal/Junctional. An independent, slower atrial rhythm is present. There is no conduction of atrial impulses to the ventricles. Since the ventricular rhythm is regular and of AV nodal origin, it is evident that no atrial impulse has activated the ventricles.
R26 Complete AV Block Similar to Complete AV Dissociation, the atria and ventricles beat independently of one another. However, the atrial rate is much faster than the ventricular rate, with the atrial rate range usually between normal and tachycardia and the ventricular rate range typically between normal and bradycardia.
R27 Unreadable (U) Label that marks a segment of unreadable data