Modified Valsalva Maneuver vs. Standard Valsalva Maneuver on Emergency Department Patients Presenting with Supraventricular Tachycardia
ABSTRACT
Background: Supraventricular tachycardia (SVT) is a relatively common dysrhythmia among the general population and a common dysrhythmia presenting to the emergency department. Generally speaking, it is assumed the provider should attempt a vagal maneuver as first-line treatment for SVT, and the most common vagal maneuver used is the Valsalva. Current resources describing the method to perform the Valsalva are vague, and it seems that the exact procedure may vary across clinicians. Even though the Valsalva maneuver is accepted as first-line treatment, there may not be complete compliance with this maneuver and many emergency departments rely relatively heavily on adenosine as absolute treatment for SVT. Currently accepted methods for performing the Valsalva typically describe the patient in a sitting or semi-recumbent position prior to “bearing down” or straining. A modification in posture has been proposed and implemented in some settings and has the patient in a supine position for increased vagal stimulation. This modified Valsalva has shown promise to be more effective than the standard Valsalva maneuver.
Methods: MEDLINE-Ovid, CINAHL, and Web of Science were exhaustively searched using the keyword “modified Valsalva”. Studies were screened using inclusion and exclusion criteria. Inclusion criteria included papers in the English language, patients presenting in SVT, and comparison of modified Valsalva to a standard Valsalva. Studies were excluded if they did not include a postural modification to the Valsalva, and had no comparison to a standard Valsalva. GRADE criteria were applied to the selected studies and assessed for quality.
Results: Primary outcome was return to normal sinus rhythm (NSR) following either control or intervention. Two studies were selected for this systematic review based on inclusion and exclusion criteria. One study was a randomized controlled trial (RCT) and contained 214 participants in both the treatment (modified Valsalva) and control (standard Valsalva) group. A second study was composed of an observational case study using the modified Valsalva and retrospective case review looking at success with a standard Valsalva maneuver.
Conclusion: There is an increase in conversion from SVT to NSR using the modified Valsalva as compared to a standard Valsalva maneuver. Also notable is the increase in conversion from SVT to NSR in the RCT control group as compared to the retrospective case review. Further research into the use of the modified Valsalva maneuver in the pediatric population should be examined as well as standardization of either Valsalva maneuver on patients presenting to the emergency department in SVT.
Keywords: Modified Valsalva maneuver, supraventricular tachycardia
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REVIEWED STUDIES:
Appelboam A; Reuben A; Mann C; Gagg J; Ewings P; Barton A; Lobban T; Dayer M; Vickery J; Benger J; REVERT trial collaborators. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 386(10005):1747-53, 2015 Oct 31.
Walker S, Cutting P. Impact of modified valsalva manoeuvre in the termination of paroxysmal SVT. Emerg Med J 2010; 27: 287–91.
AUTHOR: Jacob Wheeler is currently completing his second year in the School of PA Studies at Pacific University, Oregon. He will graduate with an MS degree in August, 2016.