Device-Assisted vs Standard Valsalva Maneuver for Terminating Supraventricular Tachycardia

Modified Valsalva maneuver for treatment of supraventricular tachycardias: A Meta-analysis.

Cardiac arrhythmia, specifically paroxysmal supraventricular tachycardia (SVT), accounts for a substantial proportion of emergency medical services resources utilisation. Reconversion requires increasing the atrioventricular node's refractoriness, which can be achieved by vagal manoeuvres, pharmacological agents or electrical cardioversion. There are multiple variants of vagal manoeuvres, including the Valsalva manoeuvre (VM). While the effectiveness of the standard VM has already been systematically reviewed, there has been no such analysis for the modified VM. Compare the effectiveness of the modified VM versus the standard VM in restoring the normal sinus rhythm in adult patients with supraventricular tachycardia. Systematic review with meta-analysis of published randomised controlled trials. The primary outcome was the reconversion to a sinus rhythm. Secondary outcomes included: medication use, adverse events, length of stay in the emergency department and hospital admission. Five randomised controlled trials were included, with a combined total of 1181 participants. The meta-analysis demonstrated a significantly higher success rate for reconversion to sinus rhythm when using the modified VM compared to the standard VM in patients with an SVT (odds ratio = 4.36; 95% confidence interval, 3.30-5.76; P < 0.001). More adverse events were reported in the modified VM group, although this difference is NS (risk ratio = 1.48; 95% confidence interval, 0.91-2.42; P = 0.11). The available evidence suggests that medication use was lower in the modified VM group than the standard VM group. However, medication use could not be generalised across the different studies. None of the included studies showed a significant difference in length of stay in the emergency department. Only one study reported on hospital admission, with no significant difference between the two groups. The available evidence is highly suggestive to support the use of the modified VM compared to the standard VM in the treatment of adult patients with SVT. Meta-analysis showed a higher success rate, required less medication use, and resulted in an equal number of adverse events. However, these results cannot be regarded as definitive in the absence of higher-quality studies.

Supraventricular tachycardia (SVT) is one of the most common cardiac arrhythmias, characterized by a sudden increase in heart rate. Initial management often involves vagal maneuvers, including the Valsalva maneuver (VM) and carotid sinus massage (CSM). VM can be categorized into standard VM (sVM) and modified VM (mVM). This study aimed to synthesize the first evidence from published randomized controlled trials (RCTs) comparing the efficacy of VM versus CSM. A comprehensive search across databases, including PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar, was conducted up to July 29, 2024. The primary endpoint was the success rate of converting SVT to sinus rhythm. The dichotomous outcome was analyzed using a fixed-effect model to calculate the risk ratio (RR) and 95% confidence intervals (CI). The Risk of Bias (RoB) tool, version 2, was employed to assess bias in the included RCTs. In total, three RCTs with 346 cases were analyzed. Concerns were noted regarding potential bias related to the randomization process in all three studies. The meta-analysis of these RCTs (comprising four arms) revealed that VM had a higher success rate than CSM for treating SVT, with an RR of 1.82 (95% CI: 1.29-2.57, p<0.001). Subgroup analysis showed that the rate of conversion to sinus rhythm was significantly higher in the sVM compared to CSM (RR=1.61, 95% CI (1.13-2.29), p=0.01). Additionally, subgroup analysis of one study indicated that mVM was associated with a higher rate of SVT conversion to sinus rhythm compared to CSM (RR=9.28, 95% CI (1.25-69.13), p=0.03). In conclusion, VM demonstrated a higher success rate compared to CSM in treating SVT. Specifically, mVM was more effective than CSM in both terminating SVT and restoring sinus rhythm, though this evidence was based on a single RCT; hence, the related conclusion should be interpreted with caution and requires validation using additional RCTs. Further research in diverse patient populations and clinical settings is necessary to validate these findings and potentially support the broader use of mVM in practice. Additional well-designed, multi-center studies with diverse populations are needed to confirm these observations and provide more comprehensive guidance on SVT management. This is important to enhance the generalizability of results across different demographics and clinical settings. This approach helps ensure that treatment effectiveness is applicable to a broader range of patients, accounting for variations in age, gender, comorbidities, and regional practices.

Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial

Comparing the success rates of standard and modified Valsalva maneuvers to terminate PSVT: A randomized controlled trial

ORAL PRESENTATION

Valsalva maneuvers are the initial line in management of paroxysmal supraventricular tachycardia in hemodynamically stable children. This study aimed to compare the efficacy of modified versus standard Valsalva maneuvers on the clinical outcomes and satisfaction of children with paroxysmal supraventricular tachycardia. The study used randomized controlled trial and recruited ninety children with paroxysmal supraventricular tachycardia from Pediatric Emergency Department and Pediatric Cardiac Intensive Care Unit at Tanta University Hospitals, El-Gharbia Governorate, Egypt. The researchers divided the studied children into three equal groups of thirty. A control group that received conventional hospital care, an intervention group I that received modified Valsalva maneuver plus conventional hospital care, and an intervention group II that received standard Valsalva maneuver plus conventional hospital care. The primary outcome was the return to sinus rhythm within the first 5min of admission and the secondary outcomes were decreased dyspnea, decreased antiarrhythmic therapy use, length of stay time in hospital as well as children's satisfaction. More than half (53.3%) of the children who received the modified Valsalva maneuver returned to sinus rhythm within the first five minutes post-implementation compared to 33.3% of the children who received the standard Valsalva maneuver. Children within modified Valsalva maneuver group had a mean satisfaction score of 25.56 ± 1.67 that was significantly higher than those in the standard Valsalva maneuver group's score of 20.10 ± 2.57 (P = 0.0001). The modified version of the Valsalva maneuver was significantly more effective than the standard Valsalva maneuver in terminating supraventricular tachycardia and improving children's clinical outcomes. This included a decrease in the degree of dyspnea within the first minute from severe to moderate and reducing the need for administering antiarrhythmic drugs for management of SVT episodes. Additionally, children in the MVM group had a higher mean satisfaction score than those in the SVM group, with highly statistically significant differences. PACTR202407479098909. Registered 15/07/2024.

Background: Supraventricular tachycardia (SVT) is a common arrhythmia presenting in emergency settings and is characterized by rapid atrial activity leading to palpitations, chest pain, and hemodynamic compromise. Restoring sinus rhythm is a primary goal in acute management and can be achieved through pharmacological agents, electrical cardioversion, or vagal maneuvers. Among these, the Valsalva maneuver (VM) is a non-invasive, low-cost, and widely used technique. Despite its established use globally, limited data exist regarding its efficacy in local emergency care contexts, warranting further evaluation. Objective: To determine the efficacy of the Valsalva maneuver in the emergency management of supraventricular tachycardia. Methods: This cross-sectional study was conducted in the Department of Emergency Medicine, CMH Rawalpindi, from 15th April 2022 to 14th April 2024. A total of 192 patients aged 20–70 years, both male and female, with SVT confirmed on ECG were enrolled using non-probability consecutive sampling. Patients with myocardial infarction, aortic stenosis, pregnancy, retinopathy, raised intraocular pressure, or severe cardiopulmonary compromise were excluded. Standard and modified forms of the VM were performed under continuous ECG and vital monitoring. Efficacy was defined as reversion to sinus rhythm with a heart rate &lt;110 beats per minute within one minute of the maneuver. Data were analyzed using SPSS version 24, applying chi-square and t-tests with p ≤ 0.05 considered significant. Results: The mean age of patients was 48.52 ± 10.70 years in the standard group (n = 124) and 50.15 ± 9.69 years in the modified group (n = 68). Males comprised 51.6% of the standard group and 72.1% of the modified group. Overall efficacy of VM was 32.3% (n = 62). Standard VM was effective in 38.7% (n = 48) compared with 20.6% (n = 14) in the modified group (p = 0.010). Mean stay in the emergency room was 3.16 ± 1.84 days versus 3.07 ± 1.42 days in the two groups (p = 0.733). Conclusion: The Valsalva maneuver was effective in terminating SVT and restoring sinus rhythm. Its simplicity, safety, and cost-effectiveness make it a valuable first-line intervention in emergency settings, particularly in resource-limited environments.

Objective: To assess efficacy of modified Valsalva manoeuvre in comparison to standard Valsalva manoeuvre in treating Supraventricular tachycardia in an emergency department. Methods: It was a quasi–experiment conducted in Azra Naheed Medical College Lahore including 132 patients presented with supraventricular tachycardia (SVT) in an emergency department. Patients were equally divided and randomly assigned to receive standard Valsalva manoeuvre and modified Valsalva manoeuvre. ECG was recorded before and after the Manoeuvre. Subjects reverted back to sinus rhythm within one minute of allocated manoeuvre were considered successful. SPSS version 21 was used to manage and analyze data. Results: Mean age of participants was 40±11 years with 33% male and 66% were females. Mean duration of paroxysmal SVT in participants was 5 ± 4 years. The mean systolic and diastolic blood pressure was 112±15 and 72±10 mmHg respectively. The range of pulse rate per minute was from 136 to 240 with a mean of 184 ± 24. SVT was reverted by Valsalva Manoeuvre in 89 (67.4%) patients and did not revert by these Manoeuvers in 43 (32.6%) patients. Out of 89 reverted, 38 were reverted by performing Standard Valsalva method and 51 were reverted by performing modified Valsalva methods (p=0.025). There was no association between age, sex, duration of SVT, presence of Diabetes Mellitus, Hypertension or Ischemic Heart Disease with the effectiveness of Vagal Manoeuvre for termination to sinus rhythm. Conclusion: Modified Valsalva manoeuvre is significantly effective than the standard manoeuvre in terminating SVT without increasing adverse effects or time spent in the emergency department.

Aim: To know whether valsalva maneuver is more effective compared to modified valsalva in terminating paroxysmal supraventricular tachycardia or vice versa. Method: The study design was randomized controlled trial. This research was conducted in accident &amp; emergency department of Mayo hospital, Lahore. Duration of this study was nine months. Participants were divided in two groups, half were assigned in Standard VM group (Group A), and other half in Modified VM group (Group B). In both groups, assigned valsalva maneuver was repeated up to two times, only when paroxysmal supraventricular tachycardia did not revert to sinus rhythm on first time. In those patients, VM failed even after three attempts, antiarrhythmic medications were used. Primary outcome was defined on the basis of successful return of sinus rhythm after either by standard or modified valsalva maneuver. Results: Sixty two patients were included in this study, thirty one in each group. Out of thirty one patients in group A, two patients (3.2%) rhythm reverted to sinus, while in group B, seven patients (11.3%) rhythm reverted to sinus. The number of patients who needed rescue treatment was lower in group B -21 (77.4%) as compared to group A- 29(93.5%). Conclusion: The results of this study showed that modified VM was more effective in terminating PSVT as compared to standard VM. So, number of patients who required pharmacological cardioversion was lower in group B. Keywords: Supraventricular tachycardia (SVT), Standard valsalva maneuver (SVM), Modified valsalva maneuver (MVM)

IntroductionPatients with episodes of supraventricular tachycardia (SVT), a common heart arrhythmia, are often attended by ambulance services. International guidelines advocate treatment with the Valsalva manoeuvre (VM), but this simple physical...

Background: The return rate of supraventricular tachycardia (SVT) to sinus rhythm by the standard Valsalva maneuver (SVM) is as low as 5%–20%. Despite the limited available data in the literature, the modified Valsalva maneuver (MVM) is promising. We tested the effectiveness of the MVM for the emergency treatment of patients with SVT. Materials and Methods: In this cohort prospective study, 93 confirmed SVT cases with mean age of 47.88 ± 15.66 years and female: male ratio (1.73) across multiple centers underwent MVM. The reversion to sinus rhythm after 1 min of the maneuver, in the first or second attempt, was considered to be a success, and other conditions were considered to be a failure. Alternative therapies were administered for nonresponders. Results: The overall success rate of the reversion of SVT to sinus rhythm by using MVM in this study is 47.3%. In addition, the rate was not affected by medical and drug histories, and the rate was not substantially different among the patients having different sociodemographics, blood pressures, and pulse rate statuses. MVM has a high cardioversion rate when used for patients with SVT. We recommend using it instead of the SVM as the first-line nonpharmacologic therapy for SVT. Conclusion: The MVM has a very reasonable cardioversion rate in the setting of emergency treatment of SVT regardless of the associated sociodemographic and medical histories of patients.

Objective To explore the application effect of modified Valsalva Maneuver technique in patients with acute supraventricular tachycardia. Methods Patients with acute supraventricular tachycardia from October 2018 to March 2019 were enrolled, and the effect of cardioversion of modified Valsalva Maneuver technique was observed. The effect of cardioversion of traditional treatment in patients with acute supraventricular tachycardia from March 2018 to September 2018 was observed. Results Of the 33 patients in the experimental group, 18 cases underwent cardioversion through modified Valsalva Maneuver technique, and the cardioversion was successful in 14 cases, which was higher than that in the control group (P<0.05); the retention time in emergency room after successful cardioversion, medical expense, the rate of readmission within 6 months in the experimental group were all significantly lower than those in the control group. Conclusion Modified Valsalva Maneuver technique does not require any equipment, is simple, easy to learn, with no economic cost, and the patients do not need to worry about side effects of the drug or discomfort, and is worthy of use when terminating paroxysmal supraventricular tachycardia. Key words: Modified Valsalva Maneuver technique; Supraventricular tachycardia; Emergency department

Initial and Sustained Response Effects of 3 Vagal Maneuvers in Supraventricular Tachycardia: A Randomized, Clinical Trial.

POSTER PRESENTATIONS