REVERT

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Appelboam A, et al. "Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial". The Lancet. 2015. epub:.
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Clinical Question

In patients with supraventricular tachycardia, does a modified Valsalva maneuver improve the rate of conversion to sinus rhythm compared to the standard Valsalva?

Bottom Line

A modified Valsalva maneuver converted a significantly higher proportion of patients with supraventricular tachycardia into normal sinus rhythm.

Major Points

Though vagal maneuvers are consistently recommended as first-line treatment for supraventricular tachycardia due to having a low risk for adverse events, they also have historically low rates of efficacy (5-20%) at conversion to sinus rhythm.

In the REVERT trial (2015), investigators examined a modified Valsalva in a randomized controlled trial which demonstrated superior efficacy to traditional vagal maneuvers, featuring a 43% rate of conversion of SVT to sinus rhythm. To perform this modified maneuver, Valsalva was performed for 60 seconds in a 45° position followed immediately by a switch to being laid flat with legs raised by a member of staff to 45° for 15 seconds. In each position, the 45 degree angle allows for optimization of change in blood flow.

Given the low risk and superior efficacy of this modified maneuver, it is likely to become the new standard of care for SVT abatement and can potentially be taught to patients at risk for recurrent SVT.

Guidelines

No guidelines currently reflect the modified Valsalva maneuver at this time.

Design

  • Multicenter randomized, controlled trial
  • N=433
  • Standard Valsalva (n=216)
  • Modified Valsalva (n=217)
  • Setting: 10 centers in the UK
  • Enrollment: January 2013 - December 2014
  • Analysis: Intention-to-treat
  • Primary outcome: Sinus rhythm at 1 minute after Valsalva by EKG

Population

Inclusion Criteria

  • Age ≥18 years
  • Supraventricular tachycardia

Exclusion Criteria

  • Unstable patients, with SBP<90 or indication for immediate cardioversion
  • Atrial fibrillation, atrial flutter, or sinus tachycardia
  • Contraindication to Valsalva (Aortic stenosis, recent MI, glaucoma, retinopathy)
  • Inability to perform Valsalva, lie flat, or have legs lifted

Baseline Characteristics

No significant differences between groups.
  • Demographics: Age 55 years, 60% female, 4% ischemic heart disease
  • Similar comorbidities (DM2, HTN, Pneumonia, COPD, valvular disease)
  • Similar vitals (SBP, DBP, HR, O2 sat)

Interventions

Patients were randomized to:

  • Standard Valsalva (n=216), renamed "Stay sitting Valsalva" to reduce bias.
    • Description: 60 second strain positioned semi-recumbent (at 45°)
  • Modified Valsalva (n=217), renamed "Lying down with leg lift Valsalva" to reduce bias.
    • Description: 60 second strain in a 45° position followed immediately by a switch to being laid flat with legs raised by a member of staff to 45° for 15 seconds
  • A 3-lead ECG was used 1 minute after initial Valsalva to reassess cardiac rhythm. If still not in sinus, participants were invited one further attempt at the allocated Valsalva maneuver.
  • A 12-lead ECG was used 1 minute after initial or second Valsalva attempt to determine final cardiac rhythm, even if unsuccessful.

Outcomes

Comparisons are standard vs. modified.

Primary Outcomes

Conversion to sinus rhythm
17% vs 43% (OR 3.7; 95% CI 2.3-5.8; P<0.0001)

Secondary Outcomes

Adenosine given
69% vs. 50% (OR 0.45; 95% CI 0.30-0.68; P<0.0002
Emergency anti-arrhythmic treatment
80% vs. 57% (OR 0.33; 95% CI 0.21-0.51; p<0.0001)
No significant differences in discharge from ED or time spent in ED

Adverse Events

No significant differences in adverse events

Criticisms

  • Though the Modified Vagal maneuver appears to be safe and effective, it does not appear to confer any advantages to adenosine in terms of safety, tolerability, efficacy, or hospital resources
  • Clinicians were not masked to treatment allocation, although this is unlikely to have skewed results given the objective and algorithmic treatment pathway for SVT

Funding

Funded by National Institute for Health Research. No conflicts of interest declared or identified.

Further Reading