Postural Modification to Valsalva Maneuver Improves Effectiveness

Study Questions:

In patients presenting to the emergency department for treatment of supraventricular tachycardia, does a postural modification to the Valsalva maneuver improve the effectiveness of this intervention in restoration of sinus rhythm?


REVERT was a pragmatic, randomized, multicenter, parallel group trial conducted in 10 emergency departments in England. Patients with suspected supraventricular tachycardia (at emergency department or initial assessment) were screened for participation. Unstable patients and those in atrial fibrillation or flutter were excluded. For both groups, the Valsalva maneuver strain was standardized to a pressure of 40 mm Hg sustained for 15 seconds by forced expiration. In the modified Valsalva maneuver, participants performed the standardized strain in the same semi-recumbent position, but immediately at the end of the strain, were laid flat and had their legs raised to 45 degrees for 15 seconds. Participants were then returned to the semi-recumbent position for a further 45 seconds before re-assessment of cardiac rhythm. The primary outcome was the presence of sinus rhythm 1 minute after the Valsalva maneuver.


A total of 433 participants were randomly assigned: 93 (43%) of 214 participants in the modified Valsalva maneuver group versus 37 (17%) of 214 participants in the standard Valsalva maneuver group achieved the primary outcome of sinus rhythm at 1 minute (odds ratio, 3.7; 95% confidence interval, 2.3-5.8; p < 0.0001). No serious adverse events were reported.


A postural modification to the Valsalva maneuver (with leg elevation and supine positioning at the end of the strain) is more effective than the standard Valsalva maneuver in restoration of sinus rhythm in patients with supraventricular tachycardia.


This is an important and clever study that demonstrates the merits of a physiologically plausible, simple, and cost-effective modification to the Valsalva maneuver for the treatment of supraventricular tachycardia. More than 40% of patients returned to sinus rhythm following this modified maneuver. Such a modification should be considered to be routine treatment.

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