Efficacy and economic benefits of a modified Valsalva maneuver in patients with paroxysmal supraventricular tachycardia

Efficacy and safety of modified Valsalva maneuver for treatment of paroxysmal supraventricular tachycardia: a meta-analysis

OBJECTIVE

To compare the efficacy and safety of the modified versus standard Valsalva maneuver in the treatment of paroxysmal supraventricular tachycardia (PSVT).

METHODS

The PubMed, Embase, Web of Science, CNKI, WanFang Data, and VIP electronic databases were searched to identify studies comparing the modified and standard Valsalva maneuvers in the treatment of PSVT from database inception to 1 May 2023. Two reviewers independently screened the literature, extracted the data, and assessed the risk of bias of all included studies.

RESULTS

Nineteen randomized controlled trials involving 2527 patients with PSVT were included. The overall rate of cardioversion was higher in the modified than standard Valsalva group (risk ratio [RR] = 1.80, 95% confidence interval [CI] = 1.61-2.01), as was the success rate of cardioversion after a single Valsalva maneuver (RR = 2.05, 95% CI = 1.74-2.41). There was no statistically significant difference in adverse reactions between the two groups (RR = 1.07, 95% CI = 0.82-1.38).

CONCLUSION

Current evidence suggests that the modified Valsalva maneuver can significantly improve the success rate of cardioversion in patients with PSVT without increasing adverse reactions. The modified Valsalva maneuver is therefore worth promoting and should be considered as a routine first treatment.INPLASY registration number: 2023100092.

Effectiveness of modified Valsalva maneuver by using wide bore syringe for emergency treatment of supraventricular tachycardias: Findings from Pakistan

Background and Objectives

The Valsalva maneuver (VM) is the most effective measure that can be carried out to treat supraventricular tachycardia (SVT). Our objective was to compare the efficacy of postural modified VM with 20 ml syringe to standard VM for the emergency treatment of SVT.

Methods

This randomized control trial study was conducted at the Accident and Emergency Department, Pakistan ordinance factories hospital, Wah Cantt from July 2019 to September 2020. In the standard Valsalva group, fifty patients were placed at an angle of 45 with continuous monitoring of vitals and electrocardiogram. Patients blew into a 20ml syringe to generate 40 mmHg pressure for 15 seconds and remained in the same position for 45 seconds before a reassessment of cardiac rhythm at one-minute and three-minute intervals. In the modified Valsalva group same procedure was repeated with the other fifty patients, but immediately at the end of the strain, they were laid flat with their legs raised to 45° for 15 seconds. Participants returned to semi-recumbent position and cardiac rhythm was reassessed after 45 seconds and then at one and three minutes.

Results

In the standard Valsalva maneuver (SVM)20.0% of participants versus 58% of participants in the modified Valsalva maneuvers group(MVM) reverted to sinus rhythm at one min (odds ratio or 5.52, 95% CI 2.26-13.47; p<0.001) and time of stay in the emergency room was (odds ratio or 2.39, 95% CI 1.45- 3.93; p<0.0001).

Conclusion

Modified Valsalva by using a wide-bore syringe is more effective method than standard Valsalva in terminating SVT.

Comparison of Various Vagal Maneuvers for Supraventricular Tachycardia by Network Meta-Analysis

BACKGROUND

Vagal maneuvers (VagMs) are recommended as the first-line treatment of supraventricular tachycardia (SVT). However, the optimal type of VagMs remains unproven.

AIM

This study aims to compare the effectiveness and adverse events amongst VagMs on SVT via network meta-analyses (NMAs).

METHODS

We systematically searched randomized controlled trials (RCTs) that involved adults with SVT and compared VagMs without language restrictions. We determined the initial and final responses of conversion rate to sinus rhythm and adverse events. Risk of bias (RoB) was appraised by Cochrane revised tool, and contribution matrix was calculated. NMAs were synthesized using frequentist random-effects model and presented as relative risk (RR) with 95% CI. The order of probability was presented as surface under the cumulative ranking curve analysis (SUCRA). Sensitivity analysis was performed using both Bayesian and frequentist approach with fixed- or random-effects models. Certainty of evidence (CoE) was rated by using the Grading of Recommendations, Assessment, Development, and Evaluations methodology.

RESULTS

Fourteen RCTs with 2,180 patients were enrolled. Small portion of mixed estimates was contributed from high overall RoB studies. Compared with carotid sinus massage (CSM), the modified Valsalva maneuver (MVM) was the most effective VagM after initial performance [SUCRA: 0.9992, RR: 5.47 (1.77-16.93)] and at the end of study [SUCRA: 1.0000, RR: 3.62 (2.04-6.39), CoE: high]. The standard VM did not elicit better conversion rate to the sinus rhythm than CSM at the initial response [SUCRA: 0.4395, RR: 1.97 (0.63-6.15)] and at the end of the study [SUCRA: 0.4795, RR: 1.64 (0.94-2.87), CoE: moderate]. The SUCRA value of CSM at the initial and final responses was the least one amongst three VagMs (0.0613 and 0.0205, respectively). Adverse events amongst three VagMs were similar (CoE: low). Sensitivity analyses yielded consistent results.

CONCLUSION

We recommended MVM as the first choice of VagM for rhythm conversion before the pharmacological management of SVT.

Effectiveness of the modified Valsalva manoeuvre in adults with supraventricular tachycardia: a systematic review and meta-analysis

BACKGROUND AND IMPORTANCE

Cardiac arrhythmia, specifically paroxysmal supraventricular tachycardia (SVT), accounts for a substantial proportion of emergency medical services resources utilisation. Reconversion requires increasing the atrioventricular node's refractoriness, which can be achieved by vagal manoeuvres, pharmacological agents or electrical cardioversion. There are multiple variants of vagal manoeuvres, including the Valsalva manoeuvre (VM). While the effectiveness of the standard VM has already been systematically reviewed, there has been no such analysis for the modified VM.

OBJECTIVES

Compare the effectiveness of the modified VM versus the standard VM in restoring the normal sinus rhythm in adult patients with supraventricular tachycardia.

DESIGN

Systematic review with meta-analysis of published randomised controlled trials.

OUTCOME MEASURES

The primary outcome was the reconversion to a sinus rhythm. Secondary outcomes included: medication use, adverse events, length of stay in the emergency department and hospital admission.

MAIN RESULTS

Five randomised controlled trials were included, with a combined total of 1181 participants. The meta-analysis demonstrated a significantly higher success rate for reconversion to sinus rhythm when using the modified VM compared to the standard VM in patients with an SVT (odds ratio = 4.36; 95% confidence interval, 3.30-5.76; P < 0.001). More adverse events were reported in the modified VM group, although this difference is NS (risk ratio = 1.48; 95% confidence interval, 0.91-2.42; P = 0.11). The available evidence suggests that medication use was lower in the modified VM group than the standard VM group. However, medication use could not be generalised across the different studies. None of the included studies showed a significant difference in length of stay in the emergency department. Only one study reported on hospital admission, with no significant difference between the two groups.

CONCLUSIONS

The available evidence is highly suggestive to support the use of the modified VM compared to the standard VM in the treatment of adult patients with SVT. Meta-analysis showed a higher success rate, required less medication use, and resulted in an equal number of adverse events. However, these results cannot be regarded as definitive in the absence of higher-quality studies.

Modified Valsalva maneuver for treatment of supraventricular tachycardias: A Meta-analysis

BACKGROUD

Valsalva maneuver (VM) is a simple and easy method for acute termination of supraventricular tachycardia (SVT), while a postural modification to the VM has been suggested to be superior to the standard VM (SVM). The objective of this meta-analysis is to explore the efficacy and safety of the modified VM (MVM) to terminate SVT compared with the SVM.

METHODS

Extensive literature was conducted using the database such as PubMed, Embase, Web of Science, Cochrane library and included randomized controlled trials (RCTs) assessing the efficacy and safety of the MVM and SVM for SVT. Meta-analysis was performed using mean difference (MD), relative risk (RR) and 95% confidence interval (CI). Statistical analysis was performed using Review Manager 5.4.1 software. The quality of the published studies was evaluated using the Oxford quality scoring system (Jadad scale).

RESULTS

Six RCTs involving 1208 patients were reviewed, including 603 patients in the MVM group and 605 patients in the SVM group. The results of the meta-analysis showed that MVM was found to significantly increase the success rate of the sinus rhythm after single VM (RR = 2.83; 95% CI = 2.19 to 3.66; P < 0.00001), sinus rhythm after multiple VM (RR = 3.83; 95% CI = 2.26 to 6.50; P < 0.00001), and single and multiple VM (RR = 2.85, 95% CI = 2.35 to 3.45; P < 0.00001). MVM also decreased the emergency anti-arrhythmic treatments (RR = 0.70; 95% CI = 0.62 to 0.79; P < 0.00001), and use of adenosine and verapamil (RR = 0.69; 95% CI = 0.61 to 0.78; P < 0.00001). There was no significant difference in adverse events (RR = 1.48; 95% CI = 0.91 to 2.42; P = 0.11) and time in emergency department (ED) (RR = 0.03; 95% CI = -0.17 to 0.23, P = 0.79) between MVM and SVM.

CONCLUSION

Compared with MVM, the conversion rate of SVT to sinus rhythm was more effective than SVM. MVM also reduced the use of anti-arrhythmic measures and drugs, and had no increased time in ED and adverse events.