Comparison of Treatment of Supraventricular Tachycardia by Valsalva Maneuver and Carotid Sinus Massage

doi:10.1016/S0196-0644(98)70277-X

Annals of Emergency Medicine

Volume 31, Issue 1, January 1998, Pages 30-35

Presented in part at the Fifth International Conference on Emergency Medicine, London, United Kingdom, May 23-26, 1994.

https://doi.org/10.1016/S0196-0644(98)70277-X Get rights and content

Abstract

Study objective: To compare the efficacy of the Valsalva maneuver with that of carotid sinus massage (CSM) in terminating paroxysmal supraventricular tachycardia (SVT) in the ED. Methods: This prospective, randomized case study was performed in the ED of a tertiary care institution. Patients were at least 10 years of age with regular narrow complex tachycardia and had an ECG diagnosis of SVT. Patients with regular narrow complex tachycardia were randomly assigned to undergo either the Valsalva maneuver or CSM. If the tachycardia was not terminated by the method chosen by randomization, then the alternative method of vagal maneuver was used. If the tachycardia was not converted by both methods of vagal stimulation, patients would undergo either synchronized electrical cardioversion or a pharmacologic method of conversion at the discretion of the treating physician, depending on the patient's hemodynamic status. Results: One hundred forty-eight instances of SVT were studied. Sixty-two patients underwent Valsalva maneuver first with conversion in 12 (success rate of 19.4%). Eighty-six underwent CSM first with conversion in 9 (success rate 10.5%). Carotid sinus massage was used in the 50 cases of SVT in which conversion was not achieved with the Valsalva maneuver. Conversion occurred in 7 cases (success rate 14.0%). For the 77 cases of SVT in which initial CSM did not achieve conversion, conversion occurred in 13 with the Valsalva maneuver (success rate 16.9%). The Valsalva maneuver and CSM achieved conversion in a total of 41 instances of SVT (success rate 27.7%). Conclusion: Vagal maneuvers are efficacious in terminating about one quarter of spontaneous SVT cases. There is no detectable difference in efficacy between the Valsalva maneuver and CSM. [Lim SH, Anantharaman V, Teo WS, Goh PP, Tan ATH: Comparison of treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage. Ann Emerg Med January 1998;31:30-35.]

Section snippets

Methods

A prospective study was performed during an 18-month period from May 1, 1993, to October 31, 1994. The study was approved by the hospital ethics committee. All patients of at least 10 years of age who presented to our ED with regular narrow complex tachycardia were included in this study. Patients whose ED EKG revealed obvious atrial flutter, atrial fibrillation, or sinus tachycardia were excluded from the study. Those who were in hemodynamically unstable condition (defined as those with signs

Results

A total of 162 instances of regular narrow complex tachycardia in this study underwent randomization; 14 were excluded from analysis. Among the 14 patients who were excluded, 1 had atrial flutter with 1:1 conduction, 4 had atrial flutter with 2:1 conduction, 1 had sick sinus syndrome, 6 had ventricular tachycardia with left axis deviation and right bundle branch block, and 2 had sinus tachycardia. Neither vagal maneuver achieved conversion in any of these 14 cases.

For the 148 instances of SVT

Discussion

The use of vagal maneuvers to terminate paroxysmal tachycardia has been known since 1913.³ With the advent of calcium channel blockers and adenosine, the authors have noted a tendency to neglect the use of vagal maneuvers to terminate SVT. In their clinical decision analysis study, Ornato et al⁴ suggested that use of vagal maneuvers will decrease the number of patients with complications of drug therapy without altering the number of treatment failures.

The Valsalva maneuver was first described

Acknowledgements

We thank Miss Stephanie Fook Chong, MSc (McGill) biostatistician, Department of Clinical Research, Singapore General Hospital for her critical comments on the statistical analysis of the data.

References (21)

JP Ornato et al.
Treatment of paroxysmal supraventricular tachycardia in the emergency department by clinical decision analysis
Am J Emerg Med
(1988)
D Mehta et al.
Relative efficacy of various physical maneuvers in the termination of junctional tachycardia
Lancet
(1988)
KS O'Toole et al.
Intravenous verapamil in the prehospital treatment of paroxysmal supraventricular tachycardia
Ann Emerg Med
(1990)
MB Waxman et al.
Vagal techniques for termination of paroxysmal supraventricular tachycardia
Am J Cardiol
(1980)
R Gorlin et al.
The Valsalva maneuver as a test of cardiac function
Am J Med
(1957)
MV Cohen
Ventricular fibrillation precipitated by carotid sinus pressure: Case report and review of the literature
Am Heart J
(1972)
JM Askey
Hemiplegia following carotid sinus stimulation
Am Heart J
(1946)
K Wildenthal et al.
The diving reflex used to treat paroxysmal atrial tachycardia
Lancet
(1975)
R Bensen
Ein fall von innervationsstörung des herzens
Berl Klin Woch
(1880)
P Preisendörfer
Ueber reflectorische Vagusneurose
Deutsch Archiv F Klin Med
(1880)

There are more references available in the full text version of this article.

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Valsalva maneuver is a recognized treatment for supraventricular tachycardia, but in clinical setting it has a low chance to achieve successful cardioversion. Studies suggested that the postural modification of valsalva maneuver may improve the rate of cardioversion. We further modified the maneuver and conduct a multicenter randomized controlled trial to test its efficacy.
Appelboam A, Reuben A, Mann C, et al. Postural modification of the standard Valsalva maneuver for emergency treatment for supraventricular tachycardias (REVERT): a randomized controlled trial. Lancet 2015; 386 (10005):1747–53 [1].
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Citation Excerpt :
mVM also had higher conversion success rates at the first and fifth minute than sVM and CSM (37.5%, 12.1%, and 6.1%; 28.1%, 6.1%, and 3.0%, respectively). Although several studies have compared the success rates of various vagal maneuvers, this study was the first to compare all 3 vagal maneuvers and to assess the sustained response (5,6,8). In the studies for comparison of vagal maneuvers, no time frame was given for length of reversion until now (5–8).
For acute termination of supraventricular tachycardia (SVT), vagal maneuvers, including the standard Valsalva maneuver (sVM), modified Valsalva (mVM) maneuver, and carotid sinus massage (CSM), are first-line interventions. There is no criterion standard technique.
This prospective, randomized study was aimed at analyzing the success rates of these 3 vagal maneuvers as measured by sustaining sinus rhythm at the fifth minute and SVT termination.
We conducted this prospective, randomized controlled study in an emergency department (ED). We enrolled all the patients who were admitted to the ED and diagnosed with SVT. We randomly assigned them to 3 groups receiving sVM, mVM, and CSM and recorded the patients’ responses to the vagal maneuvers and SVT recurrence after vagal maneuvers.
The study was completed with 98 patients. A total of 25 (25.5%) instances of SVT were initially treated successfully with vagal maneuvers. The success rate was 43.7% (14/32 cases) from mVM, 24.2% (8/33) for sVM, and 9.1 % (3/33) for CSM (p < 0.05). At the end of the fifth minute, only 12.2% (12/98) of all patients had sinus rhythm. Sinus rhythm persisted in 28.1% (9/32) of patients in the mVM group, 6.1% (2/33) of patients in the sVM group, and 3% (1/33) in the CSM group at the fifth minute (p < 0.05).
mVM is superior to the CSM maneuver in terminating SVT and maintaining rhythm. We conclude that it is beneficial to use mVM, which is more effective and lacks side effects.
Diagnosis and Management of Paroxysmal Supraventricular Tachycardia
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^☆: From the Departments of Emergency Medicine* and Cardiology,^‡ and the Singapore Heart Center, Singapore General Hospital, Singapore.^§

^☆☆: Address for reprints: Swee Han Lim, FRCS (A&E) (Edin), Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608, 65-3214100, Fax 65-2260294

^★: 47/1/87281

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Comparison of Treatment of Supraventricular Tachycardia by Valsalva Maneuver and Carotid Sinus Massage☆,☆☆,★

Abstract

Section snippets

Methods

Results

Discussion

Acknowledgements

Am J Emerg Med

Lancet

Ann Emerg Med

Am J Cardiol

Am J Med

Am Heart J

Am Heart J

Lancet

Ein fall von innervationsstörung des herzens

Berl Klin Woch

Ueber reflectorische Vagusneurose

Deutsch Archiv F Klin Med