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NIHR Signal A new, simple postural manoeuvre can stop an abnormally fast heart rate

Published on 4 November 2015

doi: 10.3310/signal-000141

A simple postural change to the Valsalva manoeuvre (see Definitions) improves the effectiveness of this cheap, non-invasive means of treating supraventricular tachycardia - an abnormally fast heart rate over 100 beats per minute. The NIHR funded a pragmatic trial of the promising technique in ten hospital emergency departments in England. The trial found that laying people flat and raising their legs, just after the Valsalva blowing, or ‘strain’ phase, was three times more effective at bringing their heart rhythm back to normal than performing the whole manoeuvre in the usual semi-reclining position. The findings add to existing guidance and have the potential to reduce the need for more interventional treatments, such as intravenous adenosine, which may have unpleasant side effects.

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Why was this study needed?

Supraventricular tachycardia occurs in just over 2 in 1,000 people and involves periods of abnormally fast heart rate (over 100 heartbeats a minute) often followed by a rapid return to a normal heart rate. Most episodes are harmless, don't last long and settle on their own without treatment, but some can last for longer causing dizziness, fainting, chest pain and difficulty breathing, particularly if there is an underlying heart condition. In these cases hospital treatment might be needed. Some people find the heart rate can be returned to normal using the “Valsalva manoeuvre” (see Definitions), but the success rate is quite low, ranging from 19% to 54%. It involves forcefully blowing out against resistance, similar to blowing up a balloon. This trial was the first to test whether a simple modification to the Valsalva manoeuvre could improve its success rate in the hospital emergency room setting. A randomised trial against current practice, in real life practice, is the best way to reliably test a new intervention.

What did this study do?

The REVERT trial was a randomised controlled trial of a modification to the Valsalva manoeuvre in real-life practice in 10 emergency departments in the South West of England. The trial included 428 participants with supraventricular tachycardia who did not have very low blood pressure or need immediate treatment to return their heart rates to normal. Participants were randomly allocated to receive the standard Valsalva manoeuvre or its modification, which could be repeated if the first attempt was unsuccessful. The main outcome was success rate at achieving normal heart rhythm, as measured one minute after the manoeuvre, using an electrocardiogram. The trial was designed rigorously, and carefully ensured that an independent expert checked each electrocardiogram, so we can be confident in the results.

What did it find?

  • Those receiving the modified Valsalva manoeuvre were more likely to regain normal heart rhythm (43% success) compared with those receiving the standard Valsalva manoeuvre (17% success). The odds ratio was 3.7, 95% confidence interval 2.3 to 5.8.
  • There was no difference between the groups in terms of the amount of time spent in the emergency department or need for hospital admission.
  • There were no serious adverse events, and no significant difference between minor adverse events in either group.

What does current guidance say on this issue?

The Resuscitation Council UK 2010 guidelines recommend that vagal manoeuvres such as the Valsalva manoeuvre are the first line intervention for people with uncomplicated supraventricular tachycardia. Another vagal manoeuvre is carotid sinus massage but they advise this should only be performed by medical personnel with access to defibrillators. If these techniques do not return the heart back to a normal rhythm within seconds, then treatment with intravenous adenosine is recommended.

What are the implications?

The modification improves the effectiveness of the original Valsalva manoeuvre for treating supraventricular tachycardia. It is cheap, safe, quick and easy to apply in the emergency department, and potentially more acceptable to people with supraventricular tachycardia than drug treatments such as intravenous adenosine. The authors noted potential for clinicians to teach the modified manoeuvre to eligible patients, which could enable them to treat themselves at home. Overall, the modification has the potential to challenge existing guidance and practice, may save resources and improve patient satisfaction.

Citation

Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015 DOI: 10.1016/s0140-6736(15)61485-4.

This project was funded by the National Institute for Health Research programme Research for Patient Benefit (grant number PB-PG-0211-24145).

Bibliography

ILCOR. International Liaison Committee on Resuscitation [internet]. 2015

Lancet TV. Postural modification to the Valsalva manoeuvre for supraventricular tachycardia. The Lancet; 2015.

Resuscitation Council (UK). Resuscitation guidelines: Peri-arrest arrhythmias. 2010

Smith GD, Fry MM, Taylor D, Morgans A, Cantwell K. Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia. Cochrane Database Syst Rev. 2015;(2):CD009502.

Tidy, C. Supraventricular tachycardia in adults [internet]. Leeds: Patient; 2013.

Why was this study needed?

Supraventricular tachycardia occurs in just over 2 in 1,000 people and involves periods of abnormally fast heart rate (over 100 heartbeats a minute) often followed by a rapid return to a normal heart rate. Most episodes are harmless, don't last long and settle on their own without treatment, but some can last for longer causing dizziness, fainting, chest pain and difficulty breathing, particularly if there is an underlying heart condition. In these cases hospital treatment might be needed. Some people find the heart rate can be returned to normal using the “Valsalva manoeuvre” (see Definitions), but the success rate is quite low, ranging from 19% to 54%. It involves forcefully blowing out against resistance, similar to blowing up a balloon. This trial was the first to test whether a simple modification to the Valsalva manoeuvre could improve its success rate in the hospital emergency room setting. A randomised trial against current practice, in real life practice, is the best way to reliably test a new intervention.

What did this study do?

The REVERT trial was a randomised controlled trial of a modification to the Valsalva manoeuvre in real-life practice in 10 emergency departments in the South West of England. The trial included 428 participants with supraventricular tachycardia who did not have very low blood pressure or need immediate treatment to return their heart rates to normal. Participants were randomly allocated to receive the standard Valsalva manoeuvre or its modification, which could be repeated if the first attempt was unsuccessful. The main outcome was success rate at achieving normal heart rhythm, as measured one minute after the manoeuvre, using an electrocardiogram. The trial was designed rigorously, and carefully ensured that an independent expert checked each electrocardiogram, so we can be confident in the results.

What did it find?

  • Those receiving the modified Valsalva manoeuvre were more likely to regain normal heart rhythm (43% success) compared with those receiving the standard Valsalva manoeuvre (17% success). The odds ratio was 3.7, 95% confidence interval 2.3 to 5.8.
  • There was no difference between the groups in terms of the amount of time spent in the emergency department or need for hospital admission.
  • There were no serious adverse events, and no significant difference between minor adverse events in either group.

What does current guidance say on this issue?

The Resuscitation Council UK 2010 guidelines recommend that vagal manoeuvres such as the Valsalva manoeuvre are the first line intervention for people with uncomplicated supraventricular tachycardia. Another vagal manoeuvre is carotid sinus massage but they advise this should only be performed by medical personnel with access to defibrillators. If these techniques do not return the heart back to a normal rhythm within seconds, then treatment with intravenous adenosine is recommended.

What are the implications?

The modification improves the effectiveness of the original Valsalva manoeuvre for treating supraventricular tachycardia. It is cheap, safe, quick and easy to apply in the emergency department, and potentially more acceptable to people with supraventricular tachycardia than drug treatments such as intravenous adenosine. The authors noted potential for clinicians to teach the modified manoeuvre to eligible patients, which could enable them to treat themselves at home. Overall, the modification has the potential to challenge existing guidance and practice, may save resources and improve patient satisfaction.

Citation

Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015 DOI: 10.1016/s0140-6736(15)61485-4.

This project was funded by the National Institute for Health Research programme Research for Patient Benefit (grant number PB-PG-0211-24145).

Bibliography

ILCOR. International Liaison Committee on Resuscitation [internet]. 2015

Lancet TV. Postural modification to the Valsalva manoeuvre for supraventricular tachycardia. The Lancet; 2015.

Resuscitation Council (UK). Resuscitation guidelines: Peri-arrest arrhythmias. 2010

Smith GD, Fry MM, Taylor D, Morgans A, Cantwell K. Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia. Cochrane Database Syst Rev. 2015;(2):CD009502.

Tidy, C. Supraventricular tachycardia in adults [internet]. Leeds: Patient; 2013.

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

Published on 1 September 2015

Appelboam, A.,Reuben, A.,Mann, C.,Gagg, J.,Ewings, P.,Barton, A.,Lobban, T.,Dayer, M.,Vickery, J.,Benger, J.

Lancet , 2015

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.

The Valsalva manoeuvre is done by breathing out moderately forcefully against resistance, (a strain). This reduces blood flow back to the heart and therefore drops blood pressure, increasing the heart rate. After some seconds normal breathing is resumed: as blood flows back into the heart, the vagus nerve is stimulated which tends to slow the heart. The manoeuvre is usually carried out in the half-reclining position. The postural modification to the Valsalva manoeuvre is demonstrated by the REVERT trial’s chief investigator in a Lancet TV video. It shows a simulation of a patient undertaking the initial strain part of the manoeuvre by blowing for 15 seconds into a modified blood pressure gauge, or into a 10ml syringe. Next the video shows the modification of the manoeuvre in the relaxation phase, health care professionals lie the patient flat and at the same time lift his legs to a 45 degree angle. The outcome of the manoeuvre is measured by assessing the heart rhythm on an electrocardiogram trace. The posture change may work by increasing the amount of blood flowing into the heart and therefore providing more stimulation of the vagus nerve.

Author commentary

With a substantial improvement in cardioversion rate, a reduced need for adenosine or other emergency treatments and no downsides identified, we believe the modified Valsalva manoeuvre has the potential to become standard practice for treatment of SVT in the UK and around the world. This would benefit many thousands of patients with no significant additional cost. Following publication of the study, hospitals within the UK, Europe and around the world are adopting this treatment into local practice. We have also written to the international committee responsible for cardiac resuscitation guidelines (ILCOR) to inform them of the study so that it might be considered for inclusion in future tachy-arrhythmia guidelines.

Dr Andrew Appelboam, Department of Emergency Medicine, Royal Devon and Exeter Hospital NHS Foundation Trust