1. Exercise Electrocardiography as an Estimation of Cardiac Function
ARTHUR M. MASTER, M.D. F.C.C.P., ISADORE ROSENFELD, M.D. F.C.C.P. 
Diseases of the Chest 
Volume 51, Issue 4, Pages (April 1967)
DOI: /chest
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

2. Figure 1 See two-step procedure in text.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

3. FIGURE 2
J. C. — Man, 46, who had been a “cardiac cripple” for 20 years. He had been in bed six weeks for two episodes of “coronary occlusion.” Each time, he received morphine for severe chest pain. A single (one and one-half minute) two-step test was negative and the next day the regular double (three minute) two-step test was also negative. Obviously, the patient had no heart disease at all. X-ray examination showed a hiatus hernia which accounted for the pain. After reassurance, the patient returned to work and has led a normal life for the past ten years.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

4. FIGURE 3
H. K. — Man, 63, with a severe anginal syndrome, almost “status anginosus.” His pain was completely relieved by iproniazid (Marsilid) but his coronary disease was unchanged as indicated by the two-step test. The control tracing showed sinus bradycardia, 37 beats per minute. Following the regular three minute two-step test, dramatic RS-T depressions and inversion of the U-wave appeared. With the cessation of drug therapy, the angina returned.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

5. FIGURE 4A
Two-step and circulatory efficiency as a function of age. FIGURE 4B: Two-step and circulatory efficiency as a function of weight.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

6. FIGURE 5
J. M. — A judge who had no cardiac symptoms and worked as a referee judge until his 100th birthday. At 101, he developed anginal pain and on his 102nd birthday, a coronary occlusion; six months later, a cerebrovascular accident occurred and he died at the age of almost 103½. The resting electrocardiogram (see A) at age 100 showed occasional ventricular premature contraction, prolongation of the P-R to 0.28 second, and right bundle branch block. The P-R prolongation had been present a few years. Post-exercise tracings revealed no significant change (B). The ventricular premature contractions persisted.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

7. FIGURE 5C
Following the onset of angina at 101 years of age, the resting electrocardiogram was still unchanged (C) but the double two-step test disclosed slight but definite “ischemic” RS-T segment depression in leads II and V5. Myocardial infarction (coronary occlusion) occurred one year later.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

8. FIGURE 6
Picture of electrodes: In the central diameter mesh, the electrode jelly is placed (see A). Band-aid type of adhesive keeps the electrode tight against the skin of the chest. The back of the disposable electrode has a clip on which the lead cable is snapped (B).
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

9. FIGURE 7
M. N. — Man, 78, who sustained a coronary occlusion 34 years ago. Since then, he has experienced severe anginal pain. The resting electrocardiogram has been stable for years and shows Q-waves in II, III, aVF and V5–6, as well as depressions (See A). The monitored single two-step test (one and one-half minute) revealed progressive changes in the ST segment and the “ischemic” pattern in the last few trips (B).
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

10. FIGURE 7C
The regular post-exercise electrocardiogram disclosed increased “ischemic” ST changes (C). Auricular premature contractions were seen both in the resting V1 and monitored tracings. In spite of the dramatic “ischemic” depressions after the exercise test and the severity of the anginal syndrome, the patient has led a good but restricted life for 34 years. He supervises a business which is distributed over the globe; he travels to his factories by air. This case again illustrates that, in spite of the general role that ST depression and coronary disease have a quantitative correlation, dramatic depressions frequently are compatible with long life.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

11. FIGURE 8
L. H. — Man, 67, physician, with an anginal syndrome. The resting electrocardiogram was negative (see A). The monitored two-step test reveals benign “j” depression on the third trip, which became abnormal on the 17th trip and still more so on the 32nd trip (B). The post-exercise (C) test disclosed “ischemic” ST depressions of only 0.5 mm in the two minute V6 tracing and at six minutes in lead II. The patient developed myocardial infarction one year later. The depth of ST depression correlates with the severity of the coronary disease only in a general way, but occasionally an “ischemic” ST depression of only 0.5 mm is significant.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

12. FIGURE 9
G. G. — Man, 51, with a six week story of substernal pressure on exertion. The resting electrocardiogram was negative (see A). At two minutes, the double two-step test revealed only 0.5 mm “ischemic” ST depression in V6 (B), but three months later, the patient experienced a severe pain; the electrocardiogram (C) now disclosed monophasic curves characteristic of acute inferior infarction. The patient died five minutes later. The degree of ST depression correlates with the severity of the coronary disease only in a general way, but occasionally an “ischemic” ST depression of only 0.5 mm is significant.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

13. FIGURES 10 AND 11
Twelve examples of insignificant “j” ST segment depressions. They return to the baseline quickly without tendency to be horizontal in type.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

14. FIGURES 10 AND 11
Twelve examples of insignificant “j” ST segment depressions. They return to the baseline quickly without tendency to be horizontal in type.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

15. FIGURE 12
Modified from Lepeschkin, E. and Surawicz, B.: New England J. Med., 258:511, 1958.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

16. FIGURE 13
S. S. — Man, 69, with angina pectoris, previous coronary occlusion. Right bundle branch block present (see A). In two-step test (B) RS-T elevations appeared in “immediate” tracing V2-V5. (A premature contraction was present in V2).
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

17. FIGURE 14
M. W.— Man, 67, with anginal syndrome, enlarged heart and diabetes. The resting electrocardiogram is essentially negative (see A). The monitored electrocardiogram shows gradual progression from a “j” or arc-like depression at the 15th trip to “ischemic” depression at the 20th trip, and still deeper depression by the 34th to 36th trips. (B). The regular post-exercise tracing revealed “ischemic” depressions in V5–6 and transitory T-wave inversions in V2–4 (C). Although this type of definite T-wave inversion is considered abnormal, it is always observed with “ischemic” ST depression.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

18. FIGURE 15
S. F. — Man, 68, physician, with long-standing hypertensive coronary disease, enlarged heart and angina pectoris. The resting electrocardiogram showed the pattern of left ventricular hypertrophy, i.e., distinct left axis deviation, ST depressions and T inversions (see A). It remained stable for years. In the monitored tracing (B) “j” (junctional) ST changes appeared which increased as the exercise continued. Ventricular premature contractions were present at the 7th trip; they formed bigeminy at the 12th and were multifocal at the 21st. Post-exercise electrocardiogram revealed no arrhythmia but there were transitory Q-waves in V2,3 and “ischemic”, sagging ST depressions in V4. The tracings had not returned to the control state 10 minutes after exercise (C).
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

19. FIGURE 16
G. B. — Man, 50, with previous coronary occlusion and severe angina pectoris (see A). Old anterior infarction evident in resting electrocardiogram. Double two-step test (B) “immediate” tracing showed 2:1 A-V block in Vs, and 3:2 A-V in V3. One atrial premature contraction was present in V6. Note dramatic “ischemic” ST depressions in post-exercise record which required 20 minutes to return to normal. The patient died six months later during strenuous play in a golf tournament.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

20. FIGURE 17
J. L.— A young physician who developed a myocardial infarction at 31 (see A). He made a complete recovery. The resting tracing (A) disclosed Q-waves in II, III, aVF, residue of the inferior infarction. The monitored two-step test (B) and the regular post-exercise electrocardiogram (C) were negative. Six years after the attack, the patient is asymptomatic and works around the clock as an oculist.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

21. FIGURE 18
M. G. — Man, 46, with severe anginal syndrome. The q in V1,2 in the resting electrocardiogram suggests an old anteroseptal infarction (see A). The monitored test showed “j” depressions, gradually increasing to almost 3 mm near the end, the 37th to the 40th trips (B). This configuration of “j” is abnormal and its appearance only at the last few trips emphasizes the need of “standardization.” The post-exercise tracing disclosed dramatic ST depressions as well as slight u-wave inversion in V4–6 (C).
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

22. FIGURE 19
J. G. — Man, 54, with previous myocardial infarction and a severe anginal syndrome. Old anterior infarction, (rS in V1–2) is evident in the resting electrocardiogram (see A). The monitored test (B) revealed an abnormal change in the ST segment only at the 24th trip. It then progressed until the 35th trip when the test was stopped because of pain. In the regular post-exercise a transitory QS appeared in V2 and dramatic depressions in V2–5 (G). This case also emphasizes the need for standardization, that is, performing the entire number of trips standardized for age, sex, and weight, all considered in the published tables.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

23. FIGURE 20
J. F. — Man, 36, with classic angina pectoris. The resting electrocardiogram was normal (see A). The monitored two-step test at first showed “j” (junctional) depressions; these became more pronounced as the exercise continued until they became “ischemic” at the very last trip, the 42nd (B). The regular post-exercise tracing showed “ischemic” depressions, maximum at two minutes in V5 (C). The monitored test showed the necessity of performing the full number of trips indicated in the published tables, since the tracing became “ischemic” only at the very end of the exercise. In other words, it is essential that exercise tests be standardized for age, sex, and weight.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

24. FIGURE 21
A. L. — Man, 40, with neurocirculatory asthenia. The resting electrocardiogram was entirely normal (see A). The monitored two-step test (B) first showed slight “j” depression at the 12th trip, which became significant on the last few trips of exercise.
Diseases of the Chest  , DOI: ( /chest )
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25. FIGURE 21C
The post-exercise electrocardiogram also revealed “ischemic” depression (see “immediate” two minute lead II and 2 minute V5–6) This is an illustration of a “false-positive” test in an extremely anxious person.
Diseases of the Chest  , DOI: ( /chest )
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26. FIGURE 22
F. E. — Man, 31, who developed rheumatic pancarditis at Annapolis during World War II. The mitral and aortic valves were involved. He made an excellent functional recovery and has played lacrosse since. A double two-step test has been negative, repeatedly (A). The teleroentgenogram revealed normal heart and lungs (B).
Diseases of the Chest  , DOI: ( /chest )
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27. FIGURE 23
N. R. — Woman, 66, with rheumatic mitral disease since childhood. She developed subacute bacterial endocarditis, but recovered on antibiotic therapy. The patient has been asymptomatic and has led a normal existence for the last 20 years, during which time the two-step test has persistently been negative.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

28. FIGURE 24
A. Z. — Woman, 46, with rheumatic heart disease, mitral stenosis and probably insufficiency, and angina pectoris. The teleroentgenogram disclosed an enlarged heart with left ventricular enlargement and straightening of the left border (see A). The Master two-step test revealed definite “ischemic” ST depression in the “immediate” and two minute V4 tracings (B). The patient died one and one-half years later. This case illustrates the occurrence of coronary insufficiency during physical effort in valvular disease.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

29. FIGURE 24
A. Z. — Woman, 46, with rheumatic heart disease, mitral stenosis and probably insufficiency, and angina pectoris. The teleroentgenogram disclosed an enlarged heart with left ventricular enlargement and straightening of the left border (see A). The Master two-step test revealed definite “ischemic” ST depression in the “immediate” and two minute V4 tracings (B). The patient died one and one-half years later. This case illustrates the occurrence of coronary insufficiency during physical effort in valvular disease.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

30. FIGURE 25
F. M. — Man, 22, with idiopathic dilatation of the pulmonary artery (lee A). A very harsh systolic murmur was heard in the pulmonary area. He was completely asymptomatic. The resting electrocardiogram (B) and the double two-step test (C) were negative. On the strength of this, he was accepted by the Army and served his “hitch” in Korea.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions

31. FIGURE 25
F. M. — Man, 22, with idiopathic dilatation of the pulmonary artery (lee A). A very harsh systolic murmur was heard in the pulmonary area. He was completely asymptomatic. The resting electrocardiogram (B) and the double two-step test (C) were negative. On the strength of this, he was accepted by the Army and served his “hitch” in Korea.
Diseases of the Chest  , DOI: ( /chest )
Copyright © 1967 The American College of Chest Physicians Terms and Conditions