title: Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial.
abstract: 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).
  
  
  RESULTS
  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<0·0001). We recorded no serious adverse events.
  
  
  CONCLUSIONS
  In patients with supraventricular tachycardia, a modified Valsalva manoeuvre with leg elevation and supine positioning at the end of the strain should be considered as a routine first treatment, and can be taught to patients.
  
  
  BACKGROUND
  National Institute for Health Research.
authors: Department of Emergency Medicine, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK. Electronic address: andy.appelboam@nhs.net.
authors: Andrew
authors: A
authors: Appelboam
authors: Department of Emergency Medicine, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK.
authors: Adam
authors: A
authors: Reuben
authors: Department of Emergency Medicine, Musgrove Park Hospital, Taunton & Somerset NHS Foundation Trust, Taunton, UK.
authors: Clifford
authors: C
authors: Mann
authors: Department of Emergency Medicine, Musgrove Park Hospital, Taunton & Somerset NHS Foundation Trust, Taunton, UK.
authors: James
authors: J
authors: Gagg
authors: University of Exeter Medical School, Exeter, UK.
authors: Paul
authors: P
authors: Ewings
authors: Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK.
authors: Andrew
authors: A
authors: Barton
authors: Arrhythmia Alliance, Stratford-upon-Avon, UK.
authors: Trudie
authors: T
authors: Lobban
authors: Department of Cardiology, Musgrove Park Hospital, Taunton & Somerset NHS Foundation Trust, Taunton, UK.
authors: Mark
authors: M
authors: Dayer
authors: Peninsula Clinical Trials Unit, Plymouth University, Plymouth, UK.
authors: Jane
authors: J
authors: Vickery
authors: Faculty of Health and Life Sciences, University of the West of England, Bristol, UK.
authors: Jonathan
authors: J
authors: Benger
mesh_terms: D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011187:Posture / Q000502:physiology; D016683:Supine Position / Q000502:physiology; D013617:Tachycardia, Supraventricular / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome; D014636:Valsalva Maneuver / Q000502:physiology