
September 14, 2015
The REVERT Trial: A Modified Valsalva Maneuver to Convert SVT
Background: In patients with cardiovascularly stable supraventricular tachycardia (SVT), the valsalva maneuver is recommended as an initial maneuver to help with cardioversion. The success rate of the valsalva maneuver alone is documented at 5 – 20%. The next option for patients who still remain in SVT is intravenous adenosine. Adenosine briefly stops all conduction through the AV node, which causes patients to feel a sense of doom or like they are about to die. Increasing venous return and vagal stimulation by laying patients supine and elevating their legs may increase the rate of conversion and is simple, safe, and cost effective.
The Modified Valsalva Maneuver:
Procedure: In a semi-recumbent position patients produce 40mmHg pressure for 15 seconds and then repositioned in a supine position with a passive leg raise immediately after the valsalva strain
What They Did:
- Multicenter, Randomized Controlled, Parallel-Group Trial in 10 emergency departments in England
- Random allocation of patients presenting with supraventricular tachycardia (SVT) in a 1:1 ratio
- Modified valsalva manoeuvre vs standard semi-recumbent valsalva manoeuvre
- Excluded patients with:
- Atrial fibrillation and flutter
- Patients with Systolic Blood Pressure of <90mmHg
Outcomes:
- Primary: Return to sinus rhythm at 1 min after intervention
- Secondary: Use of adenosine, Hospital admission, Length of Stay in ED, and Adverse Events
Results:
- 428 patients with SVT included in primary analysis
- Primary Outcome: Return to NSR at 1 min
- Standard Valsalva Arm: 37/214 (17%)
- Modified Valsalva Arm: 93/214 (43%)
- Absolute Difference = 26.2%
- NNT = 3
- Use of Adenosine:
- Standard Valsalva Arm: 148/214 (69%)
- Modified Valsalva Arm: 108/214 (50%)
- Any Adverse Event:
- Standard Valsalva Arm: 8/214 (4%)
- Modified Valsalva Arm: 13/214 (6%)
- Not Statistically Significant
- ZERO Serious Adverse Events
Strengths:
- No crossover between groups
- Zero cost impact
Limitations:
- Treating clinicians could not be blinded to treatment allocation
Discussion:
- How many things in medicine are simple, cost zero dollars, well tolerated and have zero serious adverse events? This study is a game changer in my mind. In addition fewer patients with this intervention required the impending sense of doom drug adenosine. Why would we make our patients feel like they are about to die, when we can do this one simple intervention to try and spare that?
- There was no real time saving or reduced hospital admission with the modified valsalva maneuver, but so what? Admission rate and length of stay were not increased by this maneuver either.
- Just in case you don’t have a manometer at your emergency department, it turns out that if you have a patient blow into a 10mL syringe just enough to move the plunger, you will achieve a pressure similar to 40mmHg
- One additional thing to keep in mind is with the modified valsalva maneuver, there is decreased resource utilization (i.e. No IV line, need for multiple nurses, and time taken)
Author Conclusion: In patients with SVT, 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.
Clinical Take Home Point: In patients with cardiovascularly stable SVT, a modified valsalva maneuver should be the first maneuver attempted to convert SVT. It is simple, zero cost, well tolerated, and with zero serious adverse events.
References:
- Appelboam A et al. Postural Modification to the Standard Valsalva Manoeuvre for Emergency Treatment of Supraventricular Tachycardias (REVERT): A Randomised Controlled Trial. Lancet 2015. [epub ahead of print] PMID: 26314489
For More Thoughts on This Topic Checkout:
-
- Rick Body at St. Emlyn’s: JC The REVERT Trial – Dip or Doom for SVT in the Emergency Department?
- Ryan Radecki at EMLit of Note: Valsalva 2.0
- Steve Mathieu at The Bottom Line: Postural Modification to the Standard Valsalva Manoeuvre for Emergency Treatment of Supraventricular Tachycardias (REVERT) – A Randomised Controlled Trial
- Ken Milne at The SGEM: SGEM#147 – This is a SVT and I’m Gonna REVERT It – Using a Modified Valsalva Manoeuvre
- HLTH: Fast Rhythms, Furious Management w/Salim Rezaie (Bonus Feature)
Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)
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Posted at 09:30h, 11 November[…] interested in reading more about this procedure, her are the links Laura sent Dr. Clemmens: https://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/ […]
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Posted at 08:40h, 10 August[…] Improve success of vagal maneuvers for patients in simple SVT by adding the “REVERT” maneuver: the patient performs valsalva maneuver in a semi-recumbent position, then the practitioner immediately puts the patient into a supine position with legs passively raised at a 45 degree angle. This maneuver improved conversion to NSR at 1 minute from 17% to 43%, for a NNT of 3.8. A simple way to have a patient perform a valsalva maneuver is to blow on the tip of a 10cc syringe hard enough to move the plunger. For an excellent discussion of the trial and a video of the maneuver see https://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/ […]
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Posted at 19:41h, 10 October[…] http://www.cmaj.ca/content/188/17-18/E466 Mechanism of Slow-Fast AVNRThttp:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/ AVNRT versus AVRThttp:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/ Sinus tachycardia with P waves at the end of the T-wave. Theses can be less obvious and the EKG can be mistaken for AVNRT or AVRThttp:// https://litfl.com/sinus-tachycardia-ecg-library/ Atrial fibrillation with rapid ventricular response. Not the lack of visible P waves and irregularity that make the diagnosis.http:// https://litfl.com/atrial-fibrillation-ecg-library/ Atrial flutter with 2:1 conduction. Rate of 150 and fairly obvious flutter waves are present. Atrial flutter with 2:1 conduction. Flutter waves are not overtly obvious, but the rate of 150 bpm helps suggest atrial flutter. Treatment with diltiazem will slow conduction and help reveal the flutter waves and treat the rate. Atrial flutter with 1:1 conduction. The rate of 300 and regularity of QRS complexes helps confirm the diagnosis.http:// https://litfl.com/atrial-flutter-ecg-library/ AVNRT. A regular, narrow-complex tachycardia without obvious P-waves.http:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/ AVRT in a patient with WPW. A regular, narrow-complex tachycardia without obvious P-waves.http:// https://litfl.com/pre-excitation-syndromes-ecg-library/ Junctional tachycardia. Retrograde P-waves are obvious before the QRS complexes but they are not always visible.http:// https://litfl.com/accelerated-junctional-rhythm-ajr/ Atrial fibrillation with WPW. Note the extremely rapid rate, 300 bpm at times, the wide QRS complexes and varying QRS morphologies. These features confirm the diagnosis. Another example of atrial fibrillation with WPW. This is difficult to distinguish from polymorphic ventricular tachycardia.http:// https://litfl.com/pre-excitation-syndromes-ecg-library/ 1. Patient sitting upright on stretcher2. Patient blows into syringe for 15 seconds 3. At 15 seconds quickly lay patient supine and elevate the legshttp:// https://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/ […]
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