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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 104-107

Effectiveness of the modified valsalva maneuver in the emergency management of supraventricular tachycardia


1 Department of Internal Medicine, College of Medicine, University of Duhok, Duhok, Iraqi Kurdistan, Iraq
2 Department of Internal Medicine, Azadi Teaching Hospital, Duhok General Directorate of Health, Duhok, Iraqi Kurdistan, Iraq
3 Department of Cardiac, Thoracic and Vascular Sciences, University of Padova / UNIPD, Padua, Italy

Date of Web Publication17-Jun-2019

Correspondence Address:
Mahir Sadullah Saeed
Kurdistan Board of Medical Specialties, Duhok
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJBL.MJBL_8_19

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  Abstract 


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.

Keywords: Arrhythmias, cardioversion, modified Valsalva maneuver, supraventricular tachycardia, Valsava maneuver


How to cite this article:
Mohammad AM, Saeed MS, Migliore F. Effectiveness of the modified valsalva maneuver in the emergency management of supraventricular tachycardia. Med J Babylon 2019;16:104-7

How to cite this URL:
Mohammad AM, Saeed MS, Migliore F. Effectiveness of the modified valsalva maneuver in the emergency management of supraventricular tachycardia. Med J Babylon [serial online] 2019 [cited 2019 Sep 16];16:104-7. Available from: http://www.medjbabylon.org/text.asp?2019/16/2/104/260473




  Introduction Top


Supraventricular tachycardia (SVT) is a common tachyarrhythmia presented in emergency departments.[1],[2],[3],[4] The standard Valsalva maneuver (SVM) has been a safe nonpharmacologic therapy for patients with SVT, but with a low rate of cardioversion, in the range of 5%–20%. Thus, the nonresponders are usually managed by alternative therapies such as intravenous adenosine, which might cause unpleasant feelings related to transient asystole.[5],[6],[7],[8],[9],[10] Modifying an SVM by elevating the patient legs in a supine position following the strain, which is the modified Valsalva maneuver (MVM), might enhance the cardioversion rate in patients with SVT.[11],[12]

In this regard, few studies have focused on the effectiveness of MVM in the emergency management of SVT. For instance, Appelboam et al. reported that 43% of SVT patients who underwent MVM return to sinus rhythm successfully.[10] The current study sought the cardioversion rate of patients with SVT undergoing MVM in Duhok, Iraq throughout 2017. In addition, the effectiveness of the maneuver was examined with respect to age, sex, waist circumference (WC), and sociodemographic characteristics.


  Materials and Methods Top


Ninety-three patients with SVT, who presented to six emergency departments across Duhok district in Iraq between August and December 2017, were enrolled in this study.

An electrocardiogram (ECGs) for each patient was performed and recorded before and after the completion of the maneuver. Detailed information about the patients' medical and demographic history, including sex, age, systolic blood pressure (SBP)/diastolic blood pressure (DBP) in mmHg, WC in cm, and pulse rate (PR) in beats/min, was obtained. The SVT cases were classified as undiagnosed and previously diagnosed SVT. The cases were further subdivided into either SVT alone or SVT along with other medical diseases, namely hypertension, diabetes mellitus, and ischemic heart disease. The drug history focused on antiarrhythmic drugs (e.g., beta-blockers, calcium channel blockers, amiodarone, and digoxin).

The MVM was performed through a pressure of 40 mm Hg for 15 s by forced expiration of syringe. The patients performed the strain in a semirecumbent position and were laid flat with their legs raised to a 45° angle for 15 s at the end of the strain immediately before they were returned to the semirecumbent position.[11],[13],[14] Participants were invited to attempt the maneuver a second time when the sinus rhythm was not restored.

The reverting to sinus rhythm, confirmed by an ECG after 1 min of intervention, was regarded as the primary outcome (success). If the sinus rhythm was achieved by the maneuver and using an alternative therapy, including adenosine (or other available treatments for SVT termination), it was considered to be a secondary (failure) outcome.

Patients were considered eligible for the study if they were 18 years of age or above, of either sex and presented to the hospital with SVT (regular, narrow complex tachycardia with QRS duration <0.12 s on the ECG). The patients who had atrial fibrillation/flutter, broad complex tachycardia, and hemodynamic instability or were unable to perform the maneuver were excluded from the study.

The ethical approval was obtained from the Kurdistan board of medical specialties, Kurdistan Region in Erbil, Iraq. A written consent form was obtained from all patients. The frequency and percentage of variables were performed for categorical and descriptive purposes. Mean and standard deviation was considered for the continuous characteristics of patients including, age, SBP, DBP, PR, and WC. The Chi-square test and independent t-test were performed accordingly. P ≤ 0.05 was considered to be a significant difference.


  Results Top


The mean age of the patients was 47.88 ± 15.66 years. Approximately two-thirds of the patients were women (63.4%). The mean SBP and DBP were 119.18 ± 18.26 and 76.01 ± 12.09, respectively. The mean PR was 177.50 ± 22.78. More than 25% of the SVT patients were newly diagnosed. Of the cohort, 40.9% of the patients had a drug history that included anti-arrhythmic drugs [Table 1]. The outcomes of the first and second trials of the MVM are depicted in [Table 2].
Table 1: Baseline characteristics of supraventricular tachycardia patients

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Table 2: Outcomes of the modified Valsalva maneuver in supraventricular tachycardia cases

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The study showed that 39 of 93 (41.9%) patients recovered following the first attempt of the maneuver. Of the remaining patients, 5 (9.3%) recovered following a second attempt, rendering the MVM as successful for almost half of the patients (47.3%) collectively. The remaining unrecovered patients (49%) underwent alternative therapies [Table 2].

The impact of general and medical characteristics of the cases on the cardioversion rate of the MVM was examined. Interestingly, the success rate of cardioversion by MVM was not significantly different among patients having newly diagnosed SVT compared with previously diagnosed SVT, having isolated SVT or SVT associated with other medical diseases (P = 0.075), or having a positive drug history or negative drug history (P = 0.403). Moreover, the cardioversion rate was not substantially different among patients with different sex (P = 0.409), age (P = 0.077), blood pressure (P > 0.05), PR (P = 0.374), and WC (P = 0.271) [Table 3].
Table 3: Relation of cardioversion outcome with patients' characteristics

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  Discussion Top


The overall cardioversion rate of the MVM for the emergency treatment of SVT was 47.3% in our study in Iraq. Interestingly, the study did not show whether the past medical and drug histories, different sociodemographic status, means of blood pressure, and PRs of cases could affect the cardioversion either negatively or positively. The previous limited available data concerning this maneuver demonstrated a cardioversion rate comparable to the rate in this study. In their study, Smithfound that, in comparing the modified and SVM, the success rate was 47% for the MVM and 17% in patients who underwent the SVM.[14]

The most recent study, conducted by Appelboam et al. on patients suspected with SVT in six emergency departments in southwest England, showed a lower rate compared with the current study. The authors reported that 17% of the patients achieved sinus rhythm in SVM in comparison with the 43% in the experimental MVM group.[10] We suspect that a lower rate in their study could be because of the involvement of many clinicians in the trial with a high heterogeneity bias in the delivery of procedure and maneuver performance.[12] Walker and Cutting reported a rather lower rate, and only 31.6% of the cases achieved cardioversion by the MVM in a retrospective study.[15] Interestingly, in this study, we found that all cases of SVT, whether newly diagnosed, on antiarrhythmic drugs, or associated with medical conditions, reasonably benefited from the maneuver. In our opinions, this point is highly important, especially when treating SVT with different characteristics using this maneuver especially in younger cases like ours. The significant adverse events were not recorded in the present study. However, some adverse events have been reported in other trials. Smith reported some adverse events during his study, such as hypotension, ECG changes, nausea, and musculoskeletal pain.[14] Appelboam et al. did not report any serious adverse events as well.[10] The MVM is a noninvasive and cost-effective technique for SVT patients presenting to the emergency department; however, it is essential to perform the technique of MVM correctly, as the success rate varies with different performance.[6]


  Conclusion Top


The MVM has a very reasonable cardioversion rate in the setting of emergency treatment of SVT regardless of the associated sociodemographic and past medical histories of patients. Furthermore, we recommend using this maneuver as the first-line nonpharmacological therapy for the termination of SVT attacks in our area.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Colucci RA, Silver MJ, Shubrook J. Common types of supraventricular tachycardia: Diagnosis and management. Am Fam Physician 2010;82:942-52.  Back to cited text no. 1
    
2.
Wheeler JT. Modified Valsalva Maneuver vs. standard Valsalva Maneuver on Emergency Department Patients Presenting with Supraventricular Tachycardia. School of Physician Assistant Studies Paper587; 2016.  Back to cited text no. 2
    
3.
Orejarena LA, Vidaillet H Jr., DeStefano F, Nordstrom DL, Vierkant RA, Smith PN, et al. Paroxysmal supraventricular tachycardia in the general population. J Am Coll Cardiol 1998;31:150-7.  Back to cited text no. 3
    
4.
Murman DH, McDonald AJ, Pelletier AJ, Camargo CA Jr. U.S. Emergency department visits for supraventricular tachycardia, 1993-2003. Acad Emerg Med 2007;14:578-81.  Back to cited text no. 4
    
5.
Gaspar J. Comparing Valsalva Maneuver with Carotid Sinus Massage in Adults with Supraventricular Tachycardia. BestBets; 2005.  Back to cited text no. 5
    
6.
Taylor DM, Wong LF. Incorrect instruction in the use of the Valsalva manoeuvre for paroxysmal supra-ventricular tachycardia is common. Emerg Med Australas 2004;16:284-7.  Back to cited text no. 6
    
7.
Smith G, Morgans A, Boyle M. Use of the Valsalva manoeuvre in the prehospital setting: A review of the literature. Emerg Med J 2009;26:8-10.  Back to cited text no. 7
    
8.
Lim SH, Anantharaman V, Teo WS, Goh PP, Tan AT. Comparison of treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage. Ann Emerg Med 1998;31:30-5.  Back to cited text no. 8
    
9.
Innes JA. Review article: Adenosine use in the emergency department. Emerg Med Australas 2008;20:209-15.  Back to cited text no. 9
    
10.
Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): A randomised controlled trial. Lancet 2015;386:1747-53.  Back to cited text no. 10
    
11.
Appelboam A, Gagg J, Reuben A. Modified Valsalva manoeuvre to treat recurrent supraventricular tachycardia: Description of the technique and its successful use in a patient with a previous near fatal complication of DC cardioversion. BMJ Case Rep 2014;2014. pii: bcr2013202699.  Back to cited text no. 11
    
12.
Wong LF, Taylor DM, Bailey M. Vagal response varies with Valsalva maneuver technique: A repeated-measures clinical trial in healthy subjects. Ann Emerg Med 2004;43:477-82.  Back to cited text no. 12
    
13.
Smith G, Boyle MJ. The 10 mL syringe is useful in generating the recommended standard of 40 mmHg intrathoracic pressure for the Valsalva manoeuvre. Emerg Med Australas 2009;21:449-54.  Back to cited text no. 13
    
14.
Smith GD. A modified Valsalva manoeuvre results in greater termination of supraventricular tachycardia than standard Valsalva manoeuvre. Evid Based Med 2016;21:61.  Back to cited text no. 14
    
15.
Walker S, Cutting P. Impact of a modified Valsalva manoeuvre in the termination of paroxysmal supraventricular tachycardia. Emerg Med J 2010;27:287-91.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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