The value of the master two-step test in coronary artery disease

The Value

of the Master

Coronary

Artery

RICHARD S. COSBY,

M.D.

Los Angeles,

A

STANDARDIZED exercise to be an important

detection the

of coronary

two-step

test

varied

the

such

a test

communication

and

the

disease.

criteria

for the two-step test.

test as developed worker+-”

by

Master

is of accepted

in

and the resting

normal.

It will be shown that the standardized

situations :

(1)

history,

pain

arises

the

The

is

of an atypical

tests

performed

having coronary the

by

24

artery

test was performed

of

disease.

depression

of

response.

are divided

In

into four groups

two-step of of a

of these

in \T-rlis greater

electrocardiogram to evaluate the signifIn each case the diagnosis icance of chest pain.

patients than

In only one patient

the

deleads

is T wave inver-

by S-T depression. patients

S-T

in classic

Group II

in whom

T wave inIn two precordium.

v,ersion occurs

over

the

of these

slight

S-T

depression

cordium

is also present.

included

in group ZZZ. In these two T became

inverted

in lead 1 and changed

or isoelectric

normal

response.

in whom S-T

in leads 1, 2, and V4 are charactermost

consists of three

presence

at that moment. S-T

on the electrocardiographic

1 and 2.

In 12 patients

in the

patients

depression

history

suspected

below,

in Table

The

sion accompanied

Master

patients

test was terminated

Group Z consists of fifteen patients

MATERIAL AND METHODS consists

patient

depending

“de

electrocardiogram.

material

one

test per-

pression

The

In

two-step

I.

by some to be dangerous)

(2) in the presence

test was employed.

results of the Master

it has been thought an abnormal

double

formed by 24 patients are summarized

istic.

and

the

RESULTS

nuovo” and acute myocardial ischemia is suspected but cannot be so diagnosed (in which and

of

for

sidered an abnormal

value in two other

chest

one case the number

1 mm or more in a classic lead or Vq was con-

is

electrocardiogram

electroof angina

Master]

chronic

equivocal

test is also of great

by

co-

artery

when

the

In all but

For reasons discussed

exercise

other

value

when

and

the

coronary

exercise

disease

The

abnormal

to assist in the diagnosis

advocated

two-step

upon the

and

non-diagnostic,

pain developed during the first minute and a half,

of abnormality.

and to enlarge

of a

steps

authors2-‘4

to evaluate

California

pectoris.

Master’

of performing

attempts

and MARY MAYO, A.B.

cardiogram

Although by

other

method

of abnormality

indications

aid in the

Test in

Disease*

ence

is considered

originated

employed,

both

This

criteria

artery as

is the one usually have

test

diagnostic

Two-Step

to upright

over

the

Only two patients from

in lead 3.

preare

inverted Group IT-

In

consists of three patients in whom S-T depression and T wave inversion are present in

six other patients the test was performed at a time shortly following (one week to tvvo months)

leads 2, 3, and Vh. Finally, there is one patient who shows T wave inversion in V?, VQ, and V.I.

of coronary

the

artery

development

6 patients *From

disease

was in doubt.

of ‘rpremonitory”

the test was performed

the University

of Southern

pain.

In

In

California

School

10

patients

performance

in the pres-

of Medicine,

pain

of the test;

Department

of Medicine

occurred

during

because

the

of this, exer-

(Cardiology),

Los Angeles.

California. 444

THE

AMERICAN

JOURNAL

OF CARDIOI.OC:\

Cosby ancl Mayo ‘ThB1.r; Resldts

of tllc Rlastrr

14.5

I Two-Step

Test

~Depression

i

Group

Patient

Resting

number

ECG

I

I

I

LVHt

2

Normal

3

Normal

4

LVH

.5

Borderline

6 7

Normal

8

Normal

9

LBBB

Prrmonitory

~

III

IV

V * Reference

Eorderline

13

Rorderline

14

Normal

15

Normal

16

Borderline

17

Normal

18

LVH

-

-

Kormal Normal

21

Borderline

22

LBBB

23

Normal

24

Borderline

line -PQ

stopped

Yes Yes

Yes Yes

3/1

Yes -

-

I

-

2

1

-

-

Yes Yes

Yes

UP Y?S

fl

Yes

Yes

‘12

-

~ T

-

inversion

in V2,3,*

hypertrophy.

branch

at

block.

this

point.

findings the

In

general,

were

DISCUSSION The

most frequently

in general

and usually lasted from three to five minutes.

All

by Master,’

electrocardiographic

completion

maximal test

patterns

had

returned

the resting level at the end of seven minutes. an occasional

patient the most abnormal

cardiogram

might

occur

at

second or fourth minute. real

correlation

between

and

the degree

of S-T

the

Usually

end

of pain

the electrocardiogram two or three minutes

the disappearance

of pain,

rapidl!

at which

returned

half or three and age.”

of the

during

“using

to

there was a

the severity depression

use appears

In

electro-

test. Ordinaril) mained abnormal

1’)s’)

+

Yes -

of the

APRIL,

+-

Yes

wgment.

electrocardiographic after

-

Yes -

YES Yes

19

bundle

level.

V,

_ _

-

20

rather

z3

infarction

Eorderline

1 LBBR--Left

tracing

Leads

I-2

1

Old

12

immediately

I.eads

inlm)

Yes

10 11

ventricular

was

/ Inversion OI T ~_ ~~~~

(mm)*

Normal

t LVH-Left

cise

of ST

-

pain

I II

Pain witll

the reafter

time the

to the resting

stated than

in 1942,“j

exercise period

criteria are:

exercise

of a T

precordiai been

graded

for weight

for abnormality,

“S-T

depression

lead

I\-ave.”

With the electrocardiography,

routinely

test

over a one and a

0.5 mm in an)- lead or flattening

version has

minute The

performed

to be the one developed

taken

first

greater or in-

advrent of lead \‘a

in addition

to the

classic leads, apparently with no change in the previously established criteria.‘i Many authors have

considered

Master’s

criteria

to

be

in-

sufficiently strict. Twiss and Sokolow,i2 for example! believe that S-T depression should be

Two-Step

446

greater

Test

in Coronary

than 1 mm in lead 1, 1.5 mm in leads 2

and 3, and 2 mm in V-4.

Disease

electrocardiographic

patterns.

In the majorit!

Mazer and Reisinger” mm in leads 1 and 3,

of patients

is the rule, presumably

related to ischemia of the

1.5 mm in lead 2 and

1.75

subendocardial

layer

of

Most

authors

S-T

Similar

in classic leads 2 and 3 arc less

lation

to the P-Q

set their

limits on 0.75 consider

from the isoelectric Criteria

for

depression

segment,

Katz” have measured

IV.

in re-

but Grossman

their segment

and

depression

Abnormal

Only

Rrspons~:

re-

been

Wener et al.?0 have studied 311 “normals.”

‘isingle”

test

abnormal

using

in

large groups of nor-

test.

per cent

the

seven

“double”

per

test.

and

Ross2? in

men had abnormal cent.

cent

showed of

greater

studying

responses

311

247

normal

normal

women

under

age

35,

six of whom showed a positive test according Master’s

criteria.

They

concluded

that

to the

routine Master two-step test resulted in too man) false positives mm

should

Thomas’3 double

and that an S-T depression be an indication

studied 263 normal two-step

test.

that

controls

in a normal

population

line between stringent

the normal

criteria

and

cscrcisc

usually

The apparent the general close

the

and could not be con-

to the

during

leads.

changes

electrocardiographic infarction

insufliciencyj. also

been

Divergent

expressed

as to the

the test in coronar)and

it unnecessary

Schaffer”‘~”

to standardize the test Master and

hour’s

that a double two-step

t)e performed

test is normal intcr\,al.

accepted

tests.

dividing

and abnormal,

more

pain,

In

the

symptoms

All

the occasional

depression

less than

ten

onl)- when the single and then only after an

tests

performed

patients

appeared

half to three minutes

by Master

one patient

on

1

who

did

between

pa-

develop

one and a

in all lout one case.

tion of the test.

The hesitation

of the patient,

pallor and the description

pain’s slow onset and subsidence are dramatic and diagnostically significant.

strating

as

It

is evident

from

studies cited above that false posi(3 to 5 per cent)

and false nega-

tives according to Master comprise up to 30 per cent of his series. ECG Patterns in Positiw Tests: Table I into four distinct the patients separates

important

is the development

electrocardiographic the onset of such patient

The

of pain is an asset in the interpreta-

mm. All authors have emphasized the superiority of Vd over the classical leads in demon-

tives do occur

arha\c

in terms of time? age or weight.

appearance

the reported

and

bear a

tients in this present series were double two-step

than those applied

depression.

a

of S-T

involvement

subendocardial

Scherf

The results of this present study seem to confirm this belief since only

S-T

S-T to INZ

precordial

of the S-T

in

disease.

two-step

variations

appear

Clvst Pain and Double Two-Stpp Test:

test should

depres-

would seem indicated.

showed S-T

in

contour

found

thought

ne\rrr

primarily

area of cardiac

resemblance

patterns

uncommon

patterns

test consist

Storch*x have maintained

of Master

in S-T

random

sidered abnormal. Thus if 1 mm is a generally

positive

tery

than

his

the results as shown in Table

the electrocardiographic

of performing

Simonson

and

exclusive.

In summarizing

methods

deviations

sion up to 1 mm represented

almost mutually

(acute coronar)-

depres-

of

coronar)-

Thus,

and T wave inversion

persons, using the S-T

are un-

it is almost

depression.

have

Finally.

Key,n5 discussed the normal and concluded

by S-T

opinions

sion up to 1 mm in 41 patients and greater 1 mm in only 6 persons.

depression

of 1

is a relatively

of abnormality.

She found

changes

by Gosby

\-t’hen it occurs

depression,

depression

ventricle.“’

patterns in acute

T wave inversion

I,

in ten, or 4 per

left

S-T

as described

accompanied

than 1 mm. Leeds and Kroopf23 studied

69 apparently

and reciprocal

insufhcienc).

than 1 mm,

Six of the ten cases had S-T

greater

the

the

Such findings parallel the distril)ution

finding.

an

over the precordium

co-workcrs.g”

two-step

an abnormal

Four

cases showed S-T depression McGurl

Master

of these showed

and

common,

electrocardiographic

mals Three

changes

usual.

line.

cent years have sufficiently studied

mm in lead

S-T depression

of the quite Just

of the abnormal

pattern immediately after pain. There has been no

in this series whose

electrocardiogram

failed to show abnormal features in the presence of pain. Thus, the performance of three minutes of exercise markedl>- influenced the ‘I‘HEAMERICAN

JOURN.41.

OF CARDIOI.OGY

447

Cosby and Mayo diagnostic

value

of the Master

Indications ,fol- Tzjo-Steb Test: indications

l’he usual indication

tion of an equivocal current

history There

chest pain.

tions in which the exercise

are three

nostically

of chronic

or re-

(3) The two-step ECG second

or acute

pain

cluration

of coronary

myocardial

insuffi-

infarction

thors”‘,“” that in such a situation ljurden

dicated.

of exercise

exhausted,

the

and thus the acquisition electrocardiographic

1. MUSTER.

established

of pain,

of an accurate

and earl)

outweighs

six patients

more

often

a half

not

otherwise

and resulted in the prompt initiation

with standard

test is

electro-

cardiogram

unsatis-

history

by a vague

of chest

pain.

Six patients

value

dramatic

S-T changes

in establishing

disease

4.

ma)- be

for normal

individuals.

electrocardiogram of latent

exercise

to the technic

mable value in confirming pectoris

should

be

chronic

angina

cardiogram

the diagnosis

and coronaryemployed

in

pectoris,

is normal

artery every

in whom

of an-

disease. patient

uith

the electro-

and gives important

tive information

in the majority

It ma)tients. when myocardial

offer

diagnostic

ischemia

It

raphy

of the month-the

.I. Sou/h Carolzr~a .Vf. .i. 52: exercise

test

insufficiency.

in the

Al!L

Simple

pa-

information

is suspected,

hausted. It is of definite value in the presence of an abnormal elecwocardiogram when the diagnosis of angina pectoris is in doubt. (2) The original Master criteria appear to be too liberal. S-T depression of 1 mm or more 1959

1956.

diagnosis

:

ot

38_.

graphic

L$hr .tfrd. 7

: 353.

study of cardiac

rest and on exercise. 7. MASTER,

A.

M..

:

aging

NUZIE, The

two-step

test.

rxercisc

S..

of coronark-

in-

1945. .\n electrocardio-

bawd

Ann. Inf.

P.~RKER, R. CL :

elcctrocardiog-

diagnosis

6. MAZER, M. and REISINGER, .J. A.

on records

.lfrd.

21 : 645.

BROXX.

R.

C:.,

electrocardiogram

at

1944. and

and the

:~Nz. .I. .\I. SC. 20-1

4.3;.

1944. 8. RISEM~N,

J.

E.

F.,

M. G.:

The

angina

pectoris:

WALLER.

.J. \‘..

electrocardiogram

S~HERF,

D.

rvercise

Fifteen

tests

years

with anpina

in coronary

12.

T%‘rss.

eucrcisc

A.

and

Significant

on

the

.&I. J.

cardiographic double

two-step

15.

M.ASTER, .4. M.:

lb.

MUSTER,

function.

The

A.:

during

test).

clectrocardiograrn

The cffc-ctof (Master

two-

insufficiency.

Studies

of elrrtro-

exercise

(modifird

Czrcz~fafion 6: 183, two-step

Anr. Henri J. 10: 495. A. M..

follow-

1948.

SOFFER.

changes

test

1952.

of myocaldial

1935.

FRIEDMAN. R.. and DACK. S.: after

1952.

1342.

A. C.:

of coronary

671,

.J.

pectoris.

chan,ces

electrocardiogram

.Zi. SC. 215:

P. N. G. and

927,

Angina

Hear/ J. 23: 498.

step test) in the dia,gnosis 14. Yr;,

.I. 43:

M.:

UNZRMAP~, D. and DEGRAFF. wercise

.I’/w I.o,i.

Thf- elwtrocaldio-

rim. He&

SoKoLolV, AI.

1934.

stenosis.

electrocardiographic

ing exercise. 13.

test.

cxer-

pwtoris

of electrocardiographic

.Lfed. 47: 2420. 1947. 11, SCHERF, D. and SWAFFER. A. I.: graphic

of

1940.

.\ standard

:lm. .J. M. SC. 188: 646.

:

BROLVN. attacks

and diagnostic

19: 683.

test for patients

on exertion. 10.

and

during

Its characteristics

.&/I. Heart J.

rise tolerance

when

normal electrocardiographic findings are present, and when other diagnostic means are ex-

43,.

Tut. .Ilr/i. 30:

exertional

as an aid in the

sufficiency.

posi-

of such

exerartq

1949.

of

is of inesti-

after

Lanrrf 272: 26, 1957.

prrsonnel.

use of thr

coronary

test performed

of Master

.Ir/r.

coronary

Electrocardiogram

significance.

(1) The standardized

simple

cfficienc\

GROSSMAN,M., WEINSTEIN, W. W.. and JL~Tz. I,. N. Tht:

pectoris.

according

APRIL,

the

1929.

: The

test.

: .\

I;. T.

circulator)-

9. RISEM~N, J. E. F. and STERN. B.:

gina

during

of thi\ teqt.

for

detection

in RAF.

Master

in

the diagnosis

th?

3. GROOM, D.:

the present series were examples of this situation. In these patients,

in

5. LEVAN, .J. B.:

useful is in the presence of an abnormal accompanied

cise

all

of therap!..

test

tables

2. ACHESON, E. D.

possible

in which the exercise

tolerance

.J. .M. SC. 177: 223,

in this

two-step test accuratel)

a diagnosis

i\nother situation

mrth-

precipitation

In

group an early positke

angina

and

21. M. and OPPENHEIMER.

exercise

be contrain-

diagnostic

diagnosis,

considerations.

of great

occurs

minute

REFEREK.CES

is sus-

the small addi-

would

But when all other

factory

Maxtrl

The hi,qhl\- diaeof both pain and an abnormal

in Lyhich

and a normal resting electrocardiogram It may be thought by some auis present.

other

one.

douljlc

test is emphasized.

pattern

pected,

ods are

of the

of the

useful ; the first of these is in the pres-

“premonitory”

tional

importance

nostic appearance

test might

be diag-

separation

normal response from the abnormal

erer-

is in the evalua-

to be a more adequate

seems

are t\vo other situa-

ence of che%t pain of recent ciency

There

test.

for the use of a standardized

cise test.

the

t\ro-step

standard

exercise

The as

a

448

Two-Step frmctional 1942.

17.

18.

19.

20.

21.

22.

test of the heart.

Am.

Test

in Coronary

Heart./. 24: 777,

.4. Id.: The two-step exercise ckctrocardiogram : A test for coronary insufficiency. Ann. Int. Med. 32: 842, 1950. SI.ORCH, S. and MASTER, A. M.: The RS-T segment, T wave and heart rate after two-step and ten per cent anoxemia tests. .J.A..&{.,4. 146: 1011 j 1951. SCHERLIS, L., SANDBERG, A. A., WENER, .J., DVORICIN, .J., and MASTER, A. M.: Efkcts of single and double two-step exercise tests upon electrocardiograms of 200 normal persons. J. ‘tit. Sinai Hosfi. 17: 242, 1950. WENER, J., SANDBERG, A. A., SCHERLIS, L., DVORKIN, J., and MASTER, A. M.: The clcctrocardiographic response to the standard two-step exercise test: C&ad. ,V. J. 68: 368, 1953. CHASTER, A. M., FIELD, L. E., and DONOSO, E.: Coronary artery disease and the two-step exercise test. iVew York J. Med. 57: 1051, 1957. M~GuRL, F. J. and Ross, R. L. : The double Master test: A study on 247 normal men. ?;-. A. Life Zn.r. M. Dir. dmerica 40: 40, 1957. hiASTER,

rkasc

23. LEEDS. AI. 1:. and KROOPF, S. S.: ‘l‘lw c-.*crcisc test in cll~c.tl.r)ca~tlingraphy. ixi(lf0lli!~, .\fPd. -9: 36. 1353. 24. ‘l’rto~~.~s. (:. B.: The cardiovasc[tlar rcsponsr of normal young adults to cvrrrise as tlrtcrminrd by the donblc Master two-step test. liull. ./oh Hqbhir~s Hos$. 25.

89: 181.

1951.

KEYS, 22.: The rlectrocardiographic cxercisr test: Chanqcs in thr scalat electrocardiogram and in the mean spatial QRS and ‘T vectors in two types of rxercise: Effect of absolntc and relative body weight and comment on normal standards. :lnz. ZZrt~,l .J. 52: 83.

SIMONSOL,

I:. and

1956.

J. c:., LLVIP~SON,D. G., and The vector-electrocardiogram in acute coronary insufficiency and in acute myocardial infarction. 11~~.fhrt J. 49: 896, 1955. 27. DURHAM, .J. R.: Negative Master tests in the prodromal state of acute myocardial inf,nction. .Z.il..\f.A. 155: 826, 1954. 28. GROSSMAN, I,. ~1. and GROSSMAN, M.: hfyocardial infarction precipitated by Master two-step test. .Z.il..‘LI..l. 158: 179, 1955. 26.

COSBY> K. S., ‘I‘ALBOT, %fAYo.

M.:

THE AMERICANJOURNAL OF CARDIOLOGY