By Harold L. Karpman, MD, FACC, FACP
Clinical Professor of Medicine, UCLA School of Medicine
Dr. Karpman reports no financial relationships relevant to this field of study.
SYNOPSIS: In patients presenting with supraventricular tachycardia, a modified Valsalva maneuver with leg elevation and supine positioning at the end of strain was demonstrated to be more effective than the standard Valsalva maneuver at restoring normal sinus rhythm.
SOURCE: Appelboam A, et al. Postural modification to the standard Valsalva maneuver for emergency treatment of supraventricular tachycardia (REVERT): A randomized controlled trial. Lancet 2015;386:1747-1753.
The Valsalva maneuver has been recognized as a safe and internationally recommended first-line emergency treatment for supraventricular tachycardia. However, its efficacy often has not been successful, requiring treatment with intravenous adenosine for effective cardioversion.1-6 However, since IV adenosine may cause transient asystole and is often associated with side effects,7 numerous attempts have been made to modify the Valsalva maneuver to improve its effectiveness.8-14 These modifications frequently have been proven to be effective, apparently because they increase the relaxation phase venous return and result in an increase in vagal stimulation.
Previously, the effects of position modification (i.e., supine positioning with leg elevation immediately after the Valsalva strain) had not been assessed in controlled trials.15 Therefore, Appelboam et al performed a randomized, controlled trial (REVERT) to assess whether a modified Valsalva maneuver was more effective than a standard Valsalva maneuver at restoring sinus rhythm in patients presenting to hospitals with supraventricular tachycardia.16 This randomized, multicenter parallel group trial was conducted in 10 emergency departments (ED) in England. Patients > 18 years of age who presented to the ED with supraventricular tachycardia were accepted into the trial, which excluded unstable patients and those in atrial fibrillation or flutter. The control subjects performed a Valsalva maneuver, which was standardized to a pressure of 40 mmHg, sustained for 15 seconds by forced expiration with participants in a semi-recumbent position on a trolley. The modified Valsalva maneuver was performed on patients who were in the same semi-recumbent position. Immediately at the end of the strain, they were laid flat and had their legs raised by a staff technician to 45° for 15 seconds and they then were returned to the semi-recumbent position for an additional 45 seconds before reassessment of cardiac rhythm. If sinus rhythm was not restored, participants were asked to perform one further attempt. Ninety-three of 214 participants in the modified Valsalva maneuver group vs 37 of 214 participants in the standard Valsalva maneuver group achieved the primary outcome of sinus rhythm at 1 minute after the intervention was performed. In both groups, for those who had sinus rhythm restored following the Valsalva maneuver, cardioversion occurred mostly after the first maneuver. However, nine patients in the standard Valsalva maneuver group and 18 in the modified Valsalva maneuver group cardioverted after the second attempt.
COMMENTARY
Appelboam et al have successfully demonstrated that a well-tolerated postural modification to the standard Valsalva maneuver is highly effective. Additionally, it is more effective than the standard Valsalva maneuver in restoring sinus rhythm in patients presenting to the ED with supraventricular tachycardia, resulting in a substantial reduction in the number of patients in need of other emergency treatments such as intravenous adenosine administration. There were no apparent negative effects to associated with the modified postural change after performing the Valsalva maneuver. Therefore, there seems to be no reason not to consider using the postural modification in all patients who present to the ED or physician’s office with acute onset supraventricular tachycardia, assuming these patients are all hemodynamically stable and without any clinical or anatomical abnormality that would prevent them from assuming the required postural change.
Since there were no noted negative effects of the postural change and since the time consumed by this procedure was relatively short, it would seem that clinicians should consider trying the standard Valsalva maneuver and/or the modified Valsalva maneuver before intervening with intravenous adenosine and/or other pharmacological agents when treating patients with acute onset supraventricular tachycardia.
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