Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial
Open accessAbstract
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. We assessed whether a postural modification to the Valsalva manoeuvre could improve its effectiveness. METHODS: We did a randomised controlled, parallel-group trial at emergency departments in England. We randomly allocated adults presenting with supraventricular tachycardia (excluding atrial fibrillation 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. This study is registered with Current Controlled Trials (ISRCTN67937027). FINDINGS: We 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). We recorded no serious adverse events. 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. FUNDING: National Institute for Health Research.
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Vagal manoeuvres terminate SVT in 19.4-54% of cases, with higher success when the patient is supine.
“Effectiveness of vagal manoeuvres in terminating SVT has been reported as between 19.4 -54%, 66 -68 with higher success rates in the supine position.69”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [69]
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- Authors
- Appelboam, A., Reuben, A., Mann, C., Gagg, J., Ewings, P., Barton, A., Lobban, T., Dayer, M., Vickery, J., & Benger, J.
- Affiliations
- Royal Devon & Exeter NHS Foundation Trust (GB)
- Musgrove Park Hospital (GB)
- University of Exeter (GB)
- University of Plymouth (GB)
- University of the West of England (GB)
- Corresponding author
- Appelboam, Andrew
- ORCID
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2015-10
- Volume
- 386
- Issue
- 10005
- Pages
- 1747-1753
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- OpenAlex
- W2154338430
- Cited by
- 226
- References
- 18
- Citations by year
- 2026: 23 · 2025: 26 · 2024: 24 · 2023: 20 · 2022: 13 · 2021: 21 · 2020: 27 · 2019: 20 · 2018: 8 · 2017: 19 · 2016: 20 · 2015: 5
- FWCI
- 12.60
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- The Lancet (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- UWE Research Repository (UWE Bristol) (submittedVersion, cc-by-nc-nd)
- Royal Devon and Exeter Research Repository (Royal Devon and Exeter) (submittedVersion, other-oa)
- Funders
- National Institute for Health Research through its Research for Patient Benefit Programme (grant number PB-PG-0211-24145)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Keywords
- supraventricular tachycardia, Valsalva maneuver, passive leg raising, sinus rhythm restoration, emergency department care, cardioversion
- MeSH terms
- Emergency Service, Hospital, Female, Humans, Male, Middle Aged, Posture, Tachycardia, Supraventricular, Valsalva Maneuver, Supine Position, Treatment Outcome
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