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Three Part Question

In [adult patients with supraventricular tachycardia]does [putting them in trendelenburg position] help [in cardioverting to sinus rhythm]?

Clinical Scenario

A 48 year old male presents to the emergency department with a history of 45 minutes of palpitations. He is otherwise well and his only past medical history is of paroxysmal SVT. His ECG confirms SVT on this occasion. You are going to attempt the valsalva manoeuvre and wonder whether the patient should stay sitting or whether the trendelenburg position would be better.

Search Strategy

Database: Ovid MEDLINE(R) <1946 to November Week 2 2016>

[exp Tachycardia, Supraventricular OR tachyarrhythmia.mp. OR svt.mp. OR tachyarrhythmia$.mp. OR exp Tachycardia OR narrow complex tachycardia.mp. OR supraventricular arrhythmia.mp.] AND [exp Head-Down Tilt OR exp Supine Position OR modified valsalva.mp. OR trendelenburg.mp. OR trendelenburg tilt.mp.]

Search Outcome

54 Search results. 3 were relevant and of high enough quality to include.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Appelboam et al, 2015, England	428 patients presenting to the Emergency Department with SVT, randomised into 2 groups (214 patients each); a modified valsalva (supine and legs raised) and a sitting valsalva group.	Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial.	Reversion to sinus rhythm at 1 minute post Valsalva manoeuvre- with up to 2 attempts.	93/214 (47%) patients in the modified valsalva manoeuvre group achieved the outcome vs 37/214 (17%) in the stay sitting valsalva manoeuvre
Mehta et al, 1988, United Kingdom	35 patients, with a history of paroxysmal SVT, had tachycardias induced for the study	Relative efficacy of various physical manoeuvres in the termination of junctional tachycardia.	Reversion to sinus rhythm in at least 2 out the 3 times tested.	Sinus rhythm was restored in 19/35 (54%) using the Valsalva in the supine position vs 7/35 (20%) using the Valsalva in the standing position.	-Small number of participants. -Unclear if comparing like for like as no detail given on standing position (i.e. forced expiration for 15 or 30 seconds).
Waxman et al, 1982, Canada	20 patients, with a history of paroxysmal SVT, had attempts to induce tachycardias at 0 degrees (supine), -20 degrees and +60 degrees	"Reflex mechanisms responsible for early spontaneous termination of paroxysmal supraventricular tachycardia."	Spontaneous termination of the SVT	9/20 (45%) achieved termination at 0 degrees vs 1/18 (6%) at 60 degrees vs 1/13 (8%) at -20 degrees	-Small number participants -Unclear methodology and failure to successfully induce SVT consistently

Comment(s)

There were numerous individual case studies and observational studies which appeared to support the use of the trendelenburg manoeuvre. It is also worth mentioning a paper by Wong et al; ‘Vagal response varies with Valsalva manoeuvre technique: a repeated-measures clinical trial in healthy subjects’ . The study was conducted on healthy subjects in sinus rhythm rather than SVT and ECG R-R intervals used as a proxy for measuring vagal tone. They found that supine positions gave the longest R-R intervals and slowest mean pulse rates. However, extrapolating this to patients in SVT may not be accurate due to additional electrophysiological and haemodynamic variations; therefore, it was not included in table 2. Other than the REVERT trial, there was a lack of high-level studies to use for this BET demonstrating the need for further trials to be conducted in the future.

Clinical Bottom Line

Using the modified Valsalva manoeuvre appears to increase the success rates of reverting patients in SVT back to sinus rhythm compared with the sitting/standing position.

References

1. Appelboam,A;  Reuben,A;  Mann,C et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015 386:1747-53.
2. Mehta, D;  Wafa, S;  Ward, D E et al. Relative efficacy of various physical manoeuvres in the termination of junctional tachycardia. Lancet 1988.28:1181–5.
3. Waxman MB; Sharma AD; Cameron DA et al. Reflex mechanisms responsible for early spontaneous termination of paroxysmal supraventricular tachycardia. Am J Cardiol 1982;49:259–72.