The REVERT trial was an elegant study with excellent methods. How often can we say that? It was genuinely a pleasure to review.
The authors from England randomized 433 patients with SVT to either a standard or modified Valsalva. Both groups were asked to generate a 40mm Hg pressure strain over 15 seconds. The standard group stopped here. But in the modified group the patients were repositioned to be supine and with a passive leg raise immediately after the Valsalva.
There is an excellent two minute video created by the authors that demonstrates the technique: https://www.youtube.com/watch?v=8DIRiOA_OsA
The primary outcome was proportion of patients in sinus rhythm at 1 minute after intervention.
In the end 17% of the standard Valsalva achieved sinus rhythm vs. 43% in the modified group. Wow!
These results are so good that I almost struggle to believe it is true. But it certainly can’t hurt to try. It would be nice to see if others are getting similar results.
Although this study used a bit of a fancy gizmo to measure 40mm of pressure, they make it clear that a standard 10ml syringe can be used. Just ask the patient blow hard enough just to move the plunger for 15 seconds. Then of course lay them supine and passively raise the legs.
If it works, whoopee! And tell them to try this at home.
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 Oct 31;386(10005):1747-53. doi: 10.1016/S0140-6736(15)61485-4