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Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia

  1. Gavin D Smith1,*,
  2. Kylie Dyson2,
  3. David Taylor3,
  4. Amee Morgans4,
  5. Kate Cantwell5

Editorial Group: Cochrane Heart Group

Published Online: 28 MAR 2013

Assessed as up-to-date: 31 JUL 2012

DOI: 10.1002/14651858.CD009502.pub2


How to Cite

Smith GD, Dyson K, Taylor D, Morgans A, Cantwell K. Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD009502. DOI: 10.1002/14651858.CD009502.pub2.

Author Information

  1. 1

    Monash University, Epidemiology and Preventative Medicine, Melbourne, Victoria, Australia

  2. 2

    Ambulance Victoria, Operations, Doncaster, Victoria, Australia

  3. 3

    Austin Health, Emergency Medicine, Heidelberg, Victoria, Australia

  4. 4

    Ambulance Victoria, Quality Review, Burwood East, Victoria, Australia

  5. 5

    Monash University, Epidemiology and Preventative Medicine, Prahan, Victoria, Australia

*Gavin D Smith, Epidemiology and Preventative Medicine, Monash University, Level 5, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. gavin.smith@monash.edu. caduceus7@bigpond.com.

Publication History

  1. Publication Status: New
  2. Published Online: 28 MAR 2013

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This is not the most recent version of the article. View current version (18 FEB 2015)

 
Characteristics of included studies [ordered by study ID]
Lim 1998

MethodsCountry: Singapore

Randomisation method: not stated


ParticipantsAge: 10 to 90 years (63 male, 63 female)

VM Group: 62

CSM Group: 86

Inclusion criteria: SVT (AVNRT or AVRT)

Exclusion criteria: Presenting arrhythmia other than AVNRT or AVRT


InterventionsVM performance: 40 mmHg pressure, 30 seconds duration, posture not reported.

Number of VM attempts: single attempt.

Group 1: Valsalva manoeuvre  [RIGHTWARDS ARROW] Right CSM  [RIGHTWARDS ARROW] Left CSM

Group 2: Valsalva manoeuvre  [RIGHTWARDS ARROW] Left CSM  [RIGHTWARDS ARROW] Right CSM

Group 3: Right CSM  [RIGHTWARDS ARROW] Left CSM  [RIGHTWARDS ARROW] Valsalva manoeuvre

Group 4: Left CSM [RIGHTWARDS ARROW] Right CSM  [RIGHTWARDS ARROW] Valsalva manoeuvre


OutcomesReversion to sinus rhythm for greater than two hours (monitored in ED on ECG for this time).


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "Patients were randomly assigned". "Each of these choices was written on a small card and placed in an envelope. The staff nurse in charge of the patient's care would draw one of these cards from the envelope".

Comment: Probably not done.

Allocation concealment (selection bias)Unclear riskQuote: "Each of these choices was written on a small card and placed in an envelope. The staff nurse in charge of the patient's care would draw one of these cards from the envelope".

Comment: Probably not adequate.

Blinding of participants and personnel (performance bias)
All outcomes
High riskDue to the nature of the interventions, participants and personnel could not be blinded.

Comment: Not done.

Blinding of outcome assessment (detection bias)
All outcomes
High riskNot reported.

Comment: Probably not done.

Incomplete outcome data (attrition bias)
All outcomes
Low riskOutcomes reported for 148/148 participants.

Selective reporting (reporting bias)Low riskOutcomes for reversion and recurrence were reported for all participants.

Other biasUnclear riskN/A

Mehta 1988

MethodsCountry: United Kingdom

Randomisation method: not stated


ParticipantsAge: 16 to 69 years (20 male, 15 female)

5 Groups with 35 participants allocated to each group

Inclusion criteria: repeatedly inducible haemodynamically stable SVT (AVNRT or AVRT)

Exclusion criteria: unsustainable induced SVT for > 5 minutes, tachyarrhythmias other than AVNRT or AVRT


InterventionsVM performance: 35 mmHg pressure, 15 and 30 seconds duration, supine posture

Number of VM attempts: maximum of two attempts** for each of three episodes of stimulated SVT

Group 1: supine VM

Group 2: standing VM

Group 3: right CSM

Group 4: left CSM

Group 5: diving reflex


OutcomesReversion (in 2 out of 3 attempts). No time frame is given for length of reversion, as these SVT episodes are induced.


Notes** a second attempt was performed if the participant failed to revert on the first attempt.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "The manoeuvres were performed in random order". "The manoeuvres were performed first during sinus rhythm or first during tachycardia in random order".

Comments: Probably not done.

Allocation concealment (selection bias)High riskNot reported

Comment: Probably not done.

Blinding of participants and personnel (performance bias)
All outcomes
High riskDue to the nature of the interventions participants and personnel could not be blinded.

Comment: Not done.

Blinding of outcome assessment (detection bias)
All outcomes
High riskNot reported

Comment: Probably not done.

Incomplete outcome data (attrition bias)
All outcomes
Low riskOutcomes reported for all interventions (35/35) and outcomes except diving reflex in sinus rhythm (32/35).

Selective reporting (reporting bias)Low riskOutcomes for reversion of SVT for supine and standing VM, right and left CSM, and DR were reported. Heart rate responses in sinus rhythm for the above interventions were also reported.

Other biasUnclear riskN/A

Wen 1998

MethodsCountry: Taiwan, ROC

Randomisation method: not stated


ParticipantsAge: 14 to 72 years (48 male, 85 female)

6 Groups with 133 participants allocated to each group

Inclusion criteria: repeatedly inducible haemodynamically stable SVT (AVNRT or AVRT)

Exclusion criteria: unsustainable (> 5 minutes) induced SVT, tachyarrhythmias other than AVNRT or AVRT


InterventionsVM performance: 35 mmHg pressure, 20 seconds duration, supine posture

Number of VM attempts: three attempts for each of three stimulated episodes of SVT

Group 1: VM

Group 2: CSM

Group 3: ice-to-face

Group 4:VM + ice-to-face

Group 5: VM + CSM

Group 6: CSM + ice-to-face


OutcomesReversion in two out of three attempts. No time frame is given for length of reversion, as these SVT episodes are induced.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "The manoeuvres were performed in random order".

Comment: Probably not done.

Allocation concealment (selection bias)High riskNot reported.

Comment: Probably not done.

Blinding of participants and personnel (performance bias)
All outcomes
High riskDue to the nature of the interventions participants and personnel could not be blinded.

Comment: Not done.

Blinding of outcome assessment (detection bias)
All outcomes
High riskNot reported.

Comment: Probably not done.

Incomplete outcome data (attrition bias)
All outcomes
Low riskOutcomes reported for all interventions and outcomes (133/133).

Selective reporting (reporting bias)Low riskOutcomes for reversion of SVT for VM, CSM and ice-to-face were reported.

Other biasUnclear riskN/A

 
Summary of findings for the main comparison. Summary of findings - induced SVT

Valsalva Manoeuvre for induced SVT

Patient or population: Patients with induced SVT

Settings: Clinical laboratory

Intervention: Valsalva Manoeuvre

Comparison: Nil

OutcomesStudyVM Performance

(posture, strain duration, pressure)
Reversion n (%)Quality of the evidence
(GRADE)

ReversionMehta 1988

Wen 1998
Supine, 15 and 30 seconds*, 35 mmHg

Supine, 30 seconds, 35 mmHg
19/35 (54.3)

61/133 (45.9)
⊕⊕⊝⊝
low

⊕⊕⊝⊝
low

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

* Although applying both 15 and 30 second strain durations, the Mehta study found no statistical significance of bradycardia effect (increased vagal tone) on participants when assessed in sinus rhythm.

 
Summary of findings 2. Summary of findings - clinical SVT

Valsalva Manoeuvre for clinical SVT (patients presenting with arrhythmia)

Patient or population: Patients presenting to emergency department with SVT

Settings: Emergency department (hospital)

Intervention: Valsalva Manoeuvre

Comparison: Nil

OutcomesStudyVM Performance

(posture, strain duration, pressure)
Reversion n (%)Quality of the evidence
(GRADE)

ReversionLim 1998Sitting**, 30 seconds, 40 mmHg12/62 (19.4)⊕⊕⊝⊝
low

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

** Although a deviation from accepted standard of performance technique, this posture is acceptable as a known method of performance in the clinical setting. Also, this posture has been demonstrated to precipitate adverse effects. The absence of reported adverse effects (such as hypotension or syncope) is not clear within the study.