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:

1. 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:

1. 1. Rick Body at St. Emlyn’s: JC The REVERT Trial – Dip or Doom for SVT in the Emergency Department?
   2. Ryan Radecki at EMLit of Note: Valsalva 2.0
   3. Steve Mathieu at The Bottom Line: Postural Modification to the Standard Valsalva Manoeuvre for Emergency Treatment of Supraventricular Tachycardias (REVERT) – A Randomised Controlled Trial
   4. Ken Milne at The SGEM: SGEM#147 – This is a SVT and I’m Gonna REVERT It – Using a Modified Valsalva Manoeuvre

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)

Creator & Founder of REBEL EM

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