Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial
Andrew Appelboam, FRCEM, Adam Reuben, FRCEM, Clifford Mann, FRCEM, James Gagg, FRCEM, Prof Paul Ewings, PhD, Andrew Barton, MSc, Trudie Lobban, MRCP, Mark Dayer, FRCP, Jane Vickery, MSc, Prof Jonathan Benger, MD on behalf of the REVERT trial collaborators
Published Online: 24 August 2015
Background: The Valsalva manoeuvre is an internationally recommended treatment for supraventricular tachycardia, but cardioversion is rare in practice (5–20%), necessitating the use of other treatments including adenosine, which patients often find unpleasant. Researchers assessed whether a postural modification to the Valsalva manoeuvre could improve its effectiveness.
Methods: The study authors did a randomised controlled, parallel-group trial at emergency departments in England. They randomly allocated adults presenting with supraventricular tachycardia (excluding atrial fi brillation and flutter) in a 1:1 ratio to undergo a modified Valsalva manoeuvre (done semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain), or a standard semi-recumbent Valsalva manoeuvre. A 40 mm Hg pressure, 15 s standardised strain was used in both groups. Randomisation, stratified by centre, was done centrally and independently, with allocation with serially numbered, opaque, sealed, tamper-evident envelopes. Patients and treating clinicians were not masked to allocation. The primary outcome was return to sinus rhythm at 1 min after intervention, determined by the treating clinician and electrocardiogram and confirmed by an investigator masked to treatment allocation.
Findings: The authors enrolled 433 participants between Jan 11, 2013, and Dec 29, 2014. Excluding second attendance by five participants, 214 participants in each group were included in the intention-to-treat analysis. 37 (17%) of 214 participants assigned to standard Valsalva manoeuvre achieved sinus rhythm compared with 93 (43%) of 214 in the modified Valsalva manoeuvre group (adjusted odds ratio 3·7 (95% CI 2·3–5·8; p<0·0001). No serious adverse events were recorded.
Interpretation: In patients with supraventricular tachycardia, a modified Valsalva manoeuvre with leg elevation and supine positioning at the end of the strain should be considered as a routine first treatment, and can be taught to patients.