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Three Part Question

In [adults with supraventricular tachycardia] which [vagal manoeuvre] is [most effective at restoring sinus rhythm]?

Clinical Scenario

A 56 year old woman arrives at A & E complaining of palpitations and lightheadedness. An ECG is performed and she is diagnosed with paroxysmal supraventricular tachycardia. She is haemodinamically stable but distressed with the palpitations. The physician attending this lady wonders which vagal manoeuvre to use before giving any drug intravenously.

Search Strategy

Medline using OVID interface, 1966 to June Week 2 2005.
EMBASE using OVID interface 1980 to 2005 Week 27
CINAHL using OVID interface 1982 to June Week 4 2005
[(exp Tachycardia, Supraventricular) or (narrow complex tachycardia.mp.) or (narrow-complex tachycardia.mp.) or (junctional tachycardia.mp.) or (supraventricular tachycardia.mp.)] AND [(vagal maneuvre$.mp.) or (vagal manoeuvre$.mp.) or (valsalva.mp.) or (diving reflex.mp.) or (exp Valsalva Maneuver) or (exp Massage/ or exp Carotid Sinus)] AND [(limit to humans and english language)]

Search Outcome

86 papers were found of which 82 were irrelevant. The remaining 4 are on the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Mehta D. et al 28/5/1988 United Kingdom	35 patients (20 males) mean age 35, in whom the SVT was haemodinamically stable and could be repeatedly induced by programmed electrical stimulation.	RCT	Physical manoeuvres terminated the PSVT	Manoeuvres terminated PSVT in 63%, p<0.001	Outcomes were not assessed blindly. Possible treatment bias.
			Compaired efficacy of the different manoeuvres in terminating the PSVT	Valsalva sucessful in 54% of patient vs right carotid massge in 17%, left carotid massage 5%, face immersion in 17%, p<0.001
Lim SH January 1998 USA	148 patients with paroxysmal supraventricular tachycardia (PSVT)	PRCT	Termination of PSVT	overal sucess rate: Valsalva 18.0% vs Carotid sinus massage 11.8%; p=NS; CI [-2.8% to 20.7%]	Outcomes were not assessed blind (possibility of bias). CSM is operator dependent. untoward events - 4 of the 16 patients undergoing had concomitant medical problems. treatments were swapped. basic data was not adequately described.
			recurrence of PSVT post-vagal manoeuvre	Valsalva 12.0% vs carotid sinus massage 6.3%; p<0.01
			Total instances of PSVT sucessfully treated by vagal manoeuvres without recurrence	24.3%
Taylor DMcD et al March 1999 USA	49 patients presenting to Emergency department over a 29 month period with a history of PSVT.	retrospective review	Restoring PSVT to sinus rhythm	Valsalva 16.7% vs Carotid sinus massage 0%	Operator bias, small numbers, lack of blinding, selection bias, patient bias, statistical significance not assessed.
			Relapse to PSVT	One patient who had been sucessfully reverted with Valsalva
Wen ZC et al 1998 Taiwan	133 patients with paroxysmal supraventricular tachycardia (48 male and 85 female patients mean age of 39 +/-8 years)	controlled randomised clinical trial	termination of PSVT	Valsalva manoeuvre 63/133 (47%) vs Carotid Sinus Massage 2/133 (2%); p<0.00001	operator bias outcomes not assessed blind sample size not justified

Comment(s)

of all the the manoeuvres examined, valsalva was the most frequently and consistently effective at terminating re-entry tachycardias and the one to produce the greatest change in cycle length in cardiac rhythm. Factors associated with sucess included younger age, male sex and AVRT rather than AVNRT. Right and left carotid sinus massage and the diving reflex were considerably less effective than the valsalva manoeuvre. Valsalva is also the simplest manoeuvre to perform. Ventricular fibrillation , monoplegia, hemiplegia, and cervicomediastinal haematoma are reported complications of carotid sinus massage. The only described potential hazard of the valsalva manoeuvre is hypotension during the straining phase, an event which was not described in any of the papers.

Clinical Bottom Line

The valsalva manoeuvre should be applied during spontaneous supraventricular tachycardia before other means of termination are attempted.

References

1. Mehta D., Wafa S, Ward DE, Camm AJ Relative efficacy of various physical manoeuvres in the termination of junctional tachycardia Lancet 1988 May 28; 1(8596):1181-5
2. Lim SH. Anantharaman V. Teo WS. Goh PP. Tan AT Comparison of treatment of supraventricular tachycardia by valsalva manoeuvre and carotid sinus massge Annals of Emergency Medicine Jan 1998; 31(1):30-5
3. Taylor DMcD, Auble TF, Yealy DM First-Line Management of Paroxysmal Supraventricular Tachycardia American Journal of Emergency Medicine March 1999; Volume 17, number 2
4. Wen ZC, Chen SA, Tai CT, Chiang CE, Chiou CW, Chang MS Electrophysiological Mechanisms and Determinants of Vagal Maneuvres for termination of Paroxysmal Supraventricular Tachycardia Circulation 1998; 98:2716-2723