Supraventricular tachycardia: back to basics

In The Lancet, Andrew Appelboam and colleagues1Appelboam A Reuben A Mann C et al.on behalf of the REVERT trial collaboratorsPostural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial.Lancet. 2015; (published online Aug 25.)http://dx.doi.org/10.1016/S0140-6736(15)61485-4PubMed Google Scholar present the findings of a simple but clinically relevant investigation of a safe and non-invasive treatment for patients with stable supraventricular tachycardia who present to emergency departments. This topic is important because patients with supraventricular tachycardia are common, often recurrent, emergency department attenders, and can require critical care interventions. A Cochrane review2Smith GD Fry MM Taylor D Morgans A Cantwell K Effectiveness of the Valsalva manoeuvre for reversion of supraventricular tachycardia.Cochrane Database Syst Rev. 2015; 2 (CD009502)Google Scholar did not find sufficient evidence to support or refute the effectiveness of the Valsalva manoeuvre to end supraventricular tachycardia. The study by Appelboam and colleagues1Appelboam A Reuben A Mann C et al.on behalf of the REVERT trial collaboratorsPostural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial.Lancet. 2015; (published online Aug 25.)http://dx.doi.org/10.1016/S0140-6736(15)61485-4PubMed Google Scholar adds significantly to the evidence base for the Valsalva manoeuvre. 214 patients were randomly assigned to each of two groups, treated with a standard semi-recumbent Valsalva manoeuvre or a modified manoeuvre (done semi-recumbent with supine repositioning and passive leg raise after the Valsalva strain). In terms of the primary endpoint, return to sinus rhythm 1 min after the intervention, 93 (43%) of 214 participants assigned to the modified Valsalva manoeuvre group achieved sinus rhythm, compared with 37 (17%) of 214 participants in the standard Valsalva manoeuvre group (adjusted odds ratio 3·7 [95% CI 2·3–5·8]). Whenever a new potential standard of care is proposed, its risks and benefits must be considered. The principle of never causing harm to patients is enshrined in the Hippocratic oath and is a concept increasingly challenged by both modern medicine and societal expectations. Although more observations are necessary, the ease and safety of the modified Valsalva manoeuvre described by Appelboam and co-workers1Appelboam A Reuben A Mann C et al.on behalf of the REVERT trial collaboratorsPostural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial.Lancet. 2015; (published online Aug 25.)http://dx.doi.org/10.1016/S0140-6736(15)61485-4PubMed Google Scholar suggest that this procedure could rapidly be incorporated into standard practice. The Valsalva manoeuvre is well known, but the technique used is variable. By using a standardised implementation of 40 mm Hg pressure, followed by supine positioning and leg elevation, Appelboam and colleagues1Appelboam A Reuben A Mann C et al.on behalf of the REVERT trial collaboratorsPostural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial.Lancet. 2015; (published online Aug 25.)http://dx.doi.org/10.1016/S0140-6736(15)61485-4PubMed Google Scholar have created a minimally invasive, straightforward procedure with which almost 50% of patients can achieve cardioversion. Blowing into a 10 mL syringe with sufficient force to move the plunger, as described by Smith and Boyle,3Smith G Boyle M The 10ml syringe is useful in generating the recommended standard of 40mmHg intrathoracic pressure for the Valsalva manoeuvre.Emerg Med Australas. 2009; 21: 449-454Crossref PubMed Scopus (29) Google Scholar will probably generate a similar pressure to that used by Appelboam and colleagues. There is no suggestion that the modified Valsalva manoeuvre will not be as effective outside hospital, although Appelboam and co-workers1Appelboam A Reuben A Mann C et al.on behalf of the REVERT trial collaboratorsPostural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial.Lancet. 2015; (published online Aug 25.)http://dx.doi.org/10.1016/S0140-6736(15)61485-4PubMed Google Scholar did not test this specifically. Thus, the technique might enable patients to avoid admission to hospital. Even when unsuccessful, it is unlikely to cause harm or significantly delay transfer to a medical facility. In fact, when the Valsalva manoeuvre fails, continued symptoms would justify presentation to an emergency department for more aggressive interventions, as occurs now in most cases. Although the accompanying study is too small to be absolutely certain of safety, there is no sign of increased risk of adverse events from attempting the modified Valsalva manoeuvre (there were no serious adverse events), and, because the attempt at self-cardioversion would take less than 30 s, it is unlikely to significantly delay seeking a higher level of care. Compared with the other options available to treat supraventricular tachycardia,4Link MS Evaluation and initial treatment of supraventricular tachycardia.N Engl J Med. 2012; 367: 1438-1448Crossref PubMed Scopus (63) Google Scholar the advantage of the Valsalva manoeuvre, regardless of being at home or in hospital, is that it helps to identify a population in whom aggressive treatment is justified. Adenosine is often used,4Link MS Evaluation and initial treatment of supraventricular tachycardia.N Engl J Med. 2012; 367: 1438-1448Crossref PubMed Scopus (63) Google Scholar but it is expensive and unpleasant for the patient, and most clinicians would prefer to avoid it if possible. Other treatments such as calcium channel blockers, β blockers, or even electrical cardioversion, have a small but important rate of adverse events.4Link MS Evaluation and initial treatment of supraventricular tachycardia.N Engl J Med. 2012; 367: 1438-1448Crossref PubMed Scopus (63) Google Scholar The modified Valsalva manoeuvre seems to be easy, inexpensive, non-invasive, and reproducible (162 different clinicians did the manoeuvre in Appelboam and colleagues' study1Appelboam A Reuben A Mann C et al.on behalf of the REVERT trial collaboratorsPostural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial.Lancet. 2015; (published online Aug 25.)http://dx.doi.org/10.1016/S0140-6736(15)61485-4PubMed Google Scholar); thus, an attempt by all patients before invasive treatment seems a reasonable part of standard of care. We declare no competing interests. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trialIn 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. Full-Text PDF Open Access