Modified Valsalva versus standard Valsalva manoeuvre in patients with paroxysmal supraventricular tachycardia in the emergency department: A randomised trial

OBJECTIVE: Vagal manoeuvres, particularly the Valsalva manoeuvre (VM), are recommended as first-line therapy for paroxysmal supraventricular tachycardia (PSVT). We aimed to compare the efficacy and safety of a modified Valsalva manoeuvre with the standard technique in terminating PSVT in the emergency department. METHODS: This prospective, randomised, parallel-group trial was conducted in the emergency department of a tertiary care hospital. Adults with stable PSVT were randomised (1:1) to receive either a modified or standard Valsalva manoeuvre. The modified manoeuvre involved a 40-mmHg strain for 15 s in a semi-recumbent position followed by immediate supine repositioning with passive leg elevation, while the standard manoeuvre comprised a 40-mmHg strain for 15 s in the semi-recumbent position alone. The primary outcome was return to sinus rhythm at 1 min, confirmed by electrocardiography. RESULTS: A total of 75 participants were enrolled (37 in the standard group and 38 in the modified group) on an intention-to-treat basis. Sinus rhythm was restored in 10 of 38 patients (26.3%) in the modified Valsalva group compared with 6 of 37 patients (16.2%) in the standard group (odds ratio 0.54; 95% CI 0.17-1.68; p > 0.05). No serious adverse events were observed in either group. CONCLUSIONS: The modified Valsalva manoeuvre demonstrated a higher, though not statistically significant, cardioversion rate compared with the standard technique. Both manoeuvres were safe and well tolerated. Larger adequately powered studies are required to establish definitive efficacy.