The Master Two Step exercise stress test.
Paul Goldfinger, MD, FACC. Re-post from Blogfinger.net 2016. .
In 1929, a brilliant doctor at Mt. Sinai Hospital in New York City, took an interest in the diagnosis of coronary heart disease. He was Arthur M. Master, MD, and he was trying to figure out how to diagnose underlying coronary artery disease in someone who seems healthy. This was at a time when there were no tools such as angiograms available.
He decided that he might be able to bring the diagnosis to the surface by having the subject perform exercise using a simple device—-a 2 step staircase which would enable the patient to exercise while being attached to an ECG machine. The Master’s Two Step test was the first exercise stress test, but it later fell into disfavor and was not in use when I began my cardiology residency at “Sinai” in the late 1960’s.
In 1963, a cardiologist at the University of Washington, Dr. Robert Bruce, developed the Bruce protocol for exercise stress testing using a treadmill. When I was in my final year of the cardiology residency at Mt. Sinai, we were required to do a clinical research project for 6 months. My fellow resident was Elliot Stein, MD who later also came to New Jersey to practice. We approached Dr. Arnold Katz, the chief at that time, regarding a project. He said, “Why don’t you do something with exercise.”
We were clueless about what to do. We then spoke to Dr. Ephraim Donoso at the hospital who said, “We have a treadmill in the basement that no one has ever used..” So we marched over to the hospital library where we discovered a paper by Dr. Bruce. There were very few published studies to guide us, no one at the hospital knew much about it, and the Bruce procedure had not been standardized.
Because treadmill testing was so new, we had to figure it out for ourselves. It took a lot of time, study and experimentation. We used Dr. Bruce’s basic protocol, but all the fine points had to be worked out. We tested volunteers. The hardest part was figuring out how to get good quality ECG strips during the motion of exercise. Dr. Master used to get his ECG strips after exercise, but that wasn’t very accurate and probably was the weak spot that doomed the two step test.
Among many questions which had to be resolved was what to do with the patient when we got him off the machine. We decided to sit him down at the end of the table. But two people nearly passed out, and we decided that the blood was pooling in their legs following exercise, so lying them down solved that problem.
6 months wasn’t enough time to do more than studying the science, designing a working protocol, and setting up the lab, so we never actually performed a research trial, but we learned a lot about exercise physiology and stress testing. Eventually we set up what would be the first treadmill exercise testing lab at the hospital where the exercise stress test was first invented by Dr. Master with his wooden two steps.
When I arrived at the Portsmouth Naval Hospital in Virginia, I thought I would be really special and introduce our testing methods there. But I was humbled when my chief Cmdr. Charlie Shaeffer had already set up their treadmill lab at that 1,400 bed teaching hospital. However, two years later, arriving at Dover General Hospital and Medical Center in New Jersey, I was able to start a cardiology department and exercise testing lab there.
A modern setup for treadmill stress testing. Quinton LabsOver the years, the treadmill stress test has been refined and made more accurate with the development of noise reduction cable technology, echocardiography and nuclear cardiology to offer more sophisticated end points beyond just the ECG. In recent years the indications for the test were carefully studied. We learned that it is not a screening test to be done on the entire population. When applied carefully it is a valuable diagnostic and prognostic tool.
JANET KLEIN AND HER PARLOR BOYS