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

Appelboam, Andrew; Reuben, Adam; Mann, Clifford; Gagg, James; Ewings, Paul; Barton, Andrew; Lobban, Trudie; Dayer, Mark; Vickery, Jane; Benger, Jonathan

Authors

Andrew Appelboam

Adam Reuben

Clifford Mann

James Gagg

Paul Ewings

Andrew Barton

Trudie Lobban

Mark Dayer

Jane Vickery

Jonathan Benger jonathan.benger@uwe.ac.uk



Abstract

© 2015 Appelboam et al. Open Access article distributed under the terms of CC BY-ND-NC. 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

Journal Article Type Article
Publication Date Oct 31, 2015
Journal The Lancet
Print ISSN 0140-6736
Electronic ISSN 1474-547X
Publisher Elsevier
Peer Reviewed Peer Reviewed
Volume 386
Issue 10005
Pages 1747-1753
Institution Citation Appelboam, A., Reuben, A., Mann, C., Gagg, J., Ewings, P., Barton, A., …Benger, J. (2015). Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): A randomised controlled trial. Lancet, 386(10005), 1747-1753. https://doi.org/10.1016/S0140-6736%2815%2961485-4
DOI https://doi.org/10.1016/S0140-6736%2815%2961485-4
Keywords RCT, randomised controlled trial, Valsalva manoeuvre, supraventricular tachycardias
Publisher URL http://dx.doi.org/10.1016/S0140-6736(15)61485-4

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