Title: Randomised Controlled Trial Evaluation of a Modified Valsalva Manoeuvre in Patients Experiencing Re-Entrant Tachycardias (REVERT) study
Funder: Department of Health (England)

Abstract: Background: Re-entrant supraventricular tachycardia (SVT) is a fast abnormal heart rhythm. Many SVT patients attend hospital with attacks of palpitations that are terminated with intravenous Adenosine. This drug causes a pause in the heart beat and is effective but associated with very unpleasant side effects: Patients often report a sense of doom and some even ‘feel they are about to die’. Although current guidelines for treating SVT advocate the initial use of physical treatments such as the Valsalva manoeuvre (VM) (an exhalation against resistance causing reflex slowing of the heart) to restore normal heart rhythm, it is often unsuccessful and then Adenosine is required. Small non-randomised trials suggest that modification to the VM may increase its effectiveness and reduce the need for Adenosine. Aims: We aim to determine whether a modification to the standard Valsalva manoeuvre (VM) increases the proportion of patients with SVT who are successfully converted to normal heart rhythm without the subsequent need for Adenosine. Reaseach Question: Does modification to the standard VM increase the proportion of patients who are successfully cardioverted to sinus rhythm in stable patients presenting to the Emergency Department with SVT? Plan of Investigation: We plan to conduct a 7 centre randomised controlled trial to compare the semi-recumbent position (sitting at 45 degrees) VM (control) versus a modified VM performed semi-recumbent but followed by lying flat with legs raised for 15 seconds on relaxation (intervention) in patients who attend the Emergency Department (ED) with SVT. The strain part of the VM will be standardised for both groups with a forced expiration against a manometer to 40mmHg pressure for 15 seconds. All eligible patients coming to the ED with SVT will be invited to participate. Consenting patients will be randomised to control or intervention groups. An ECG recorded one minute after the VM will determine return to normal heart rhythm, the primary endpoint of the study. Other outcome measures include the requirement for subsequent emergency treatment including adenosine, the patients’ length of stay in the ED and need for hospital admission. Intention to treat analysis will be undertaken blind to the treatment allocations. Potential benefits to patients and NHS: This study will show whether modification to the VM improves its efficacy. If so, this would be of immediate benefit to ED patients to minimise the duration of their symptoms and obviate the need for an intravenous canula and more invasive and unpleasant treatments. SVT can be recurrent and patients do use the VM out of hospital. Informing patients of the most effective VM would therefore empower them and potentially reduce discomfort and time lost in attending the ED. The NHS could also save money relating to ambulance calls, clinical time and drug expenditure (see also Supporting Documentation). Importantly, providing evidence as to how this routinely performed manoeuvre should best be carried out would influence standard emergency practice and resuscitation guidelines around the world.


Research activity codes: 6.7 PHYSICAL
Health categories: CARDIOVASCULAR