Effectiveness of the modified Valsalva maneuver vs the standard Valsalva maneuver for the conversion of supraventricular tachycardia to normal sinus rhythm in the emergency department: a systematic review and meta analysis

Supraventricular tachycardia (SVT) is a cardiac arrhythmia that is commonly encountered in the emergency department (ED), for which vagal maneuvers represent first-line treatment in hemodynamically stable patients. The modified Valsalva maneuver (MVM), which involves supine repositionings and leg raises that follow the strain phase, have been proposed as a more effective alternative to the standard Valsalva maneuver (SVM). We performed a systematic review and meta-analysis (SRMA) of randomized controlled trials comparing the MVM to the SVM for conversion of SVT to normal sinus rhythm in hemodynamically stable patients presenting to the ED. PubMed, Web of Science, Google Scholar, and the Cochrane Central Register of Controlled Trials were searched from inception through March 17, 2026. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and dichotomous outcomes were pooled as risk ratios (RR) with 95% confidence intervals (CIs). Nine trials comprising 1415 patients were included. The MVM achieved successful cardioversion in 50.1% of patients compared with 18.8% in the SVM group (polled RR 2.63, 95% CI 2.22–3.11; I 2 = 0%). No major adverse events were reported in either group. The MVM is significantly more effective than the SVM for terminating SVT in the ED with no major adverse events reported in either group. These findings support the MVM as a safe, low-cost, and reproducible first-line intervention for SVT cardioversion in the ED. Further randomized trials, particularly in pediatric populations and direct comparison with pharmacologic alternatives, are warranted to confirm these results.