Modified Valsalva Improves Conversion to Normal Rhythm in Supraventricular Tachycardia

October 30, 2015

EXETER, UK — Patients with supraventricular tachycardia (SVT) treated with a modified Valsalva maneuver are nearly four times more likely to return to normal sinus rhythm than individuals treated with the standard semirecumbent Valsalva maneuver, new research shows[1].

In 214 patients with SVT presenting the emergency department, the modified maneuver resulted in a return to normal sinus rhythm in 93 individuals. Comparatively, just 37 of 214 individuals with SVT treated with the standard Valsalva maneuver had a return to normal rhythm.

The difference in the return to normal sinus rhythm—43% vs 17%—was statistically significant (adjusted odds ratio 3.7; P<0.0001) and resulted in a significant reduction in the number of patients requiring other emergency treatments, such as adenosine. Adenosine, as the investigators point out, causes transient asystole and can be "frightening and unpleasant" for many patients.

In the study, published October 31, 2015 in the Lancet, lead investigator Dr Andrew Appelboam (Royal Devon and Exeter Hospital NHS Foundation Trust, UK) and colleagues explain that the modified Valsalva is performed in the same semirecumbent manner as a standardized procedure, except patients lie flat immediately at the end of the Valsalva strain and have their legs lifted by a staff member to 45 degrees for 15 seconds. Following this, the patients return to the semirecumbent position for 45 seconds before cardiac rhythm is reassessed.

With the modified technique, investigators did not identify any adverse events or disadvantages, stating the new maneuver should be considered a routine first treatment and taught to patients.

"As long as individuals can safely undertake a Valsalva strain and be repositioned as described, this maneuver can be used as the routine initial treatment for episodes of supraventricular tachycardia regardless of location," write the researchers. "The technique could prevent many patients from being treated with drugs or even seeking healthcare."

Primary and Secondary Outcomes

Outcome Standard Valsalva maneuver, n=214 (%) Modified Valsalva maneuver, n=214 (%) Adjusted odds ratio (95% CI)
Presence of sinus rhythm at 1 min after Valsalva maneuver* 17 43 3.7 (2.3–5.8)
Adenosine 69 50 0.45 (0.30–0.68)
Any emergency antiarrhythmic treatment 80 57 0.33 (0.21–0.51)
Discharged home from emergency department 68 63 0.79 (0.51–1.21)
Any adverse event 4 6 1.61 (0.63-4.08)
*Primary outcome

Although the standard Valsalva maneuver is a first-line emergency treatment for SVT, cardioversion success with the standard maneuver is poor, with success rates ranging from 5% to 20%.

In an editorial[2], Dr Martin Than (Christchurch Hospital, New Zealand) and Dr William Peacock (Baylor Medical College, Houston, TX) state the modified Valsalva maneuver "seems to be easy, inexpensive, noninvasive, and reproducible," noting that 162 clinicians performed the procedure in the study. While investigators did not test the effectiveness of the procedure outside the emergency setting, use of the modified Valsalva maneuver might help patients avoid going to the hospital, according to the editorialists.

"Even when unsuccessful, it is unlikely to cause harm or significantly delay transfer to a medical facility," they write. "In fact, when the Valsalva maneuver fails, continued symptoms would justify presentation to an emergency department for more aggressive interventions, as occurs now in most cases."

The authors and editorialists report no relevant financial relationships.

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