Robert Arthur Bruce, MD
Robert Arthur Bruce, the “father of exercise cardiology,” died in Seattle on February 12, 2004, at the age of 87 years. Born in Somerville, Mass, he received his Bachelor of Science degree from Boston College and graduated from the University of Rochester School of Medicine in 1943. He completed his internship and medical residency at the University of Rochester Strong Memorial Hospital. After service as Chief Resident in Medicine, he joined the Faculty of Medicine at the University of Rochester in 1946. In 1950, Dr Robert H. Williams, the founding Chief of Medicine at the new University of Washington School of Medicine, selected Dr Bruce to be the first Chief of Cardiology. He directed the division until 1971 and codirected with Dr Harold T. Dodge for an additional 10 years. He became Professor Emeritus in 1987 but continued to be actively interested in the division for the remainder of his life.
As a young cardiologist at the University of Rochester, Dr Bruce recognized that exercise stress testing could play an important role in the evaluation of cardiac patients. The cumbersome Master’s Two-Step test, in common use at that time, was clearly inadequate to assess respiratory and circulatory function during varying degrees of sustained exertion. He and his early coworker, Dr Paul Yu, who had recently arrived from China, collaborated to develop a treadmill exercise test. His first publication on exercise testing was in 1949, in which he reported observations relating to the basis of dyspnea in beryllium workers with cor pulmonale. After his initial experience with treadmill exercise testing, he came to the conclusion that “a technique of standardized exercise is considered satisfactory for the investigation of dyspnea in clinical patients” (Bruce et al. J Clin Invest. 1949;28;1423).
Initially, Dr Bruce and coworkers used a single-stage test, but it soon became clear that multiple stages would afford advantages. Shortly after moving to Seattle in 1950, Dr Bruce modified his test to comprise 4 progressive stages. Subsequently, the standard Bruce Exercise Treadmill Test evolved into its present form, with seven 3-minute stages.
An important achievement during his early years at the University of Washington was the conception and validation of the multistage exercise protocol in 1963. Subsequently, an extensive database was used to develop normal standards based on age, sex, and habitual pattern of activity. The duration of exercise then became the principal measurement for the estimation of what he termed “functional aerobic impairment.” Today’s near-exclusive emphasis on the ECG response to exercise is at odds with Dr Bruce’s concept of exercise testing, in which substantial attention was directed to exercise performance and heart rate and blood pressure changes, coupled with targeted examination of the patient during and immediately after exertion. From such observations, exercise-induced hypotension was identified as a manifestation of fixed stroke volume and a strong predictor of adverse long-term outcomes.
The Seattle Heart Watch program, initiated by Dr Bruce in 1971, organized a dedicated group of community physicians in hospitals, offices, and industrial practices to test the feasibility and utility of symptom-limited exercise testing in both ambulatory cardiac patients and in apparently healthy subjects. A database representing >10 000 persons was developed over the ensuing 10 years. Whereas ST-segment depression was significantly related to death within 3 years, Dr Bruce also concluded that “changes in systolic pressure during exercise merit greater attention than monitoring ST displacements.”
Bob Bruce was a caring and dedicated physician. Neither conservative nor unduly radical in formulating clinical decisions, he unfailingly maintained the utmost concern for his patients. He was an early proponent of the objective assessment of the benefits and downsides of the newly introduced valvular surgical procedures.
Dr Bruce was thoughtful and imaginative. He was one of the first to use cardiac electrode catheter pacing for cardiac arrest or third-degree heart block during the course of acute myocardial infarction. (The initial patient was Dr Williams, who had recruited Dr Bruce to the University of Washington.) Dr Bruce acquired an early interest in the use of computers in cardiology and developed a method for quantifying the QRS and ST segments during exercise. In the late 1950s, he was also one of the first to suggest the possible benefit of thrombolysis in acute myocardial infarction. Dr Bruce published >300 scientific articles; these, in aggregate, represent a major contribution to our knowledge of cardiovascular physiology in health and disease.
As a pioneer in cardiology, Dr Bruce was often invited to be a visiting professor at other institutions. He spent extended periods at several foreign institutions, including the University of Edinburgh (1965 to 1966), University of Malaya (1974), and the Academia Sinica, Taiwan (1982). As most academic physicians, he belonged to many professional organizations. Of note, he was a founding member of the Association of University Cardiologists and its second president in 1969. He was a member of the American Society of Clinical Investigation and a past president of the Western Society of Clinical Investigation. He served on study sections of the National Heart, Lung, and Blood Institute and was an advisor to the Federal Aviation Agency and the National Aeronautic and Space Administration.
For many, Bob Bruce was the quintessential academic cardiologist. In particular, he was an imaginative and highly focused clinical investigator, whose special contributions deserve high ranking in any list of important medical milestones. He will likely be best remembered for the Bruce multistage treadmill test, which by its simplicity of design became a reproducible, readily performed estimate of maximal exercise capacity and, by extension, maximal oxygen consumption. Over the period of a decade or thereabouts, the Bruce protocol became the most commonly used test of its kind in this country.
Bob Bruce was diagnosed with chronic lymphatic leukemia ≈10 years before his death. Unfortunately, he became progressively limited by spinal stenosis during his last years. Robert A. Bruce died at his home in Seattle, where many of his family, old friends, and members of the current University of Washington cardiology faculty were able to visit with him just before his death.
On a personal level, Bob Bruce was the ultimate New England gentleman. Reserved, unassuming, and kind to the core, he was an excellent teacher and mentor to a large number of physicians who went on to assume leading roles in medicine and physiology, both here and abroad. Those of us who worked closely with Dr Bruce over the years will continue to be inspired by his dedication to clinical investigation, teaching, and the care of patients that characterized his career.⇓