SVT A Simple Modification to the Valsalva Maneuver That Changes Everything
- 1 day ago
- 4 min read
Those who work in emergency care know the adrenaline rush that accompanies supraventricular tachycardias (SVTs): a frantic patient, a racing monitor, and the ever-present dilemma of how to act quickly. The Valsalva maneuver is our first ally, but—let’s face it—it rarely works the way we want it to. At least… until now.
The study from 10 years ago but that few people still know about
Published in the Lancet in 2015, the REVERT study ( Postural modification to the standard Valsalva maneuver for emergency treatment of supraventricular tachycardias ) has finally put down on paper what many of us had already intuited in the field: a small postural modification to the classic Valsalva maneuver can make a big difference.
👨⚕️ Involving more than 400 patients in 10 British emergency departments, the researchers compared the standard maneuver (in a semi-seated position at 45°) with a modified version, which involves:
Expiratory effort (40 mmHg for 15 sec)
Immediate transition to supine position
Passive leg raise at 45° for 15 sec
The result? The rate of return to sinus rhythm went from 17% to 43%. A net increase of 26%, with a NNT (Number Needed to Treat) of only 4.📉 Adenosine use was also nearly halved.
What does an NNT of 4 mean?In the world of evidence-based medicine, the NNT , or Number Needed to Treat , is one of the most powerful numbers we can use to understand how effective a treatment really is in practice. 👉 An NNT of 4 means that for every 4 patients treated with the modified Valsalva, one will avoid additional treatment (such as adenosine) compared to those receiving the standard maneuver. To understand each other better:
📊 This is an exceptional result in the emergency setting, where the NNT for pharmacological or invasive interventions is often much higher. An NNT < 10 is considered clinically significant , but an NNT of 4 is very rare , and tells us that we are truly making a difference with a simple, rapid and free gesture. Also, let's not forget: we are not only avoiding the use of adenosine, but also the side effects that accompany it — a sense of impending doom, flushing, chest pain, and marked anxiety for patients. With this maneuver, we avoid all of this in 25% of cases. This is a huge advantage on a human level as well. |
Field experience that finds confirmation
Personally, I use this modified version of Valsalva as a first choice precisely in pre-hospital settings, often in an ambulance or at the patient's home. The results are often surprising: patients who return to sinus rhythm without the need for drugs, calmer, more cooperative, and — not least — more confident in our abilities.
Outcome | Standard Valsava | Modified Valsalva |
|---|---|---|
Return to Sinus Rhythm | 17% | 43% |
Need for Adenosine | 69% | 50% |
Use of Antiarrhythmics | 80% | 57% |
Every time the modified maneuver works, I rejoice and am simultaneously amazed that, 10 years after the publication of this important study, few still apply it as a first-choice maneuver.
This study is well designed, pragmatic, performed in a real context, and demonstrates that we can be effective even with simple tools, if used intelligently.
How is the Modified Valsalva Maneuver performed?
Below is a video, taken from the magazine, that clearly shows how to do it.
What are the contraindications instead? ⚠️
Systolic pressure < 90 mmHg
Clinical instability
Atrial fibrillation or flutter
Aneurysm, recent heart attack, glaucoma, third trimester of pregnancy
Why is it important for us, pre-hospital workers?
It's safe : no serious adverse events were recorded in the study.
It can be reproduced anywhere : all you need is a stretcher (or even a bed at home) and a colleague.
It is educational : it can be taught to the patient for self-management.
And most importantly, it saves time, drugs, resources, and anxiety. Not much more is needed to call an intervention "smart."
🔎 A systematic review ten years after REVERT: confirmations and consolidation
It has been almost a decade since the publication of the REVERT Trial (2015) , but to date no randomized trial has surpassed its rigor and clinical scope in evaluating the efficacy of modified Valsalva in the treatment of supraventricular tachycardia (SVT). However, a new systematic review and meta-analysis published in Cureus in 2024 adds an important piece to the overall picture.
The authors analyzed three RCTs (for a total of 473 patients ), comparing the Valsalva maneuver (both standard and modified) with carotid sinus massage (CSM), still present in some protocols. The result is clear:
Valsalva, overall, showed significantly greater success than CSM , with a Risk Ratio (RR) of 1.82 (95% CI: 1.29–2.57, p<0.001) ;
the standard form (sVM) was superior to the CSM with RR = 1.61 (p = 0.01);
while the modified form (mVM) — analyzed in a single included RCT — showed an impressive RR = 9.28 (95% CI: 1.25–69.13, p = 0.03) .
Although the mVM data comes from only one included study, the fact that these results exactly replicate what was observed in the REVERT Trial (43% success mVM vs 17% with sVM) gives strength and coherence to the evidence. Furthermore, the review questions the safety of CSM, especially in elderly patients, where the risk of cerebral adverse events is not negligible.
In summary, REVERT remains the beacon , but we can now say that the direction indicated ten years ago has been confirmed . Modified Valsalva is a solid, effective and low-risk technique. And every new clinical evidence only reinforces its value.
Do you use it? What do your company protocols say? Write it in the comments.
Bibliography
Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomized controlled trial. Appelboam, Andrew et al.
The Lancet, Volume 386, Issue 10005, 1747 - 1753
Alfehaid AA, Almutairi OT, Albloushi MH, et al. Valsalva Maneuver Versus Carotid Sinus Massage for Supraventricular Tachycardia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cureus . 2024;16(9):e70064. Published 2024 Sep 24. doi:10.7759/cureus.70064
