CITATION

Appelboam A, Reuben A, Mann C, Gagg J. Ewings P, Barton A, Lobban T, Dayer M, Vickery J, Benger J. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial (REVERT trial). Lancet. 2015;epublished online Aug 25th.

STUDY POPULATION & QUESTION

Multicenter (two teaching and eight district general hospitals in UK) randomized controlled parallel group trial. Postural modification to Valsalva manoeuvre can improve it’s effectiveness in treatment of SVT

STUDY & COMPARATOR INTERVENTION

They allotted patients presenting with supraventricular tachycardia in a 1:1 ratio to either study group (Valsalva in semi-recumbent position i.e blowing through a pipe attached to a manometer to a pressure of 40 mm of Hg for 15 seconds followed by supine repositioning and passive leg raising for 15 seconds. It was repeated once if unsuccessful) or control group (Valsalva in semi-recumbent position i.e blowing through a pipe attached to a manometer to a pressure of 40 mm of Hg for 15 seconds only).

OUTCOME

• Primary outcome was sinus rhythm as recorded by the treating clinician 1 min after Valsalva manoeuvre and confirmed by ECG in the intention-to-treat population.

• Secondary outcomes were the use of adenosine, the use of any emergency treatment for supraventricular tachycardia (including adenosine), the need and reason for admission to hospital, the length of time participants spent in the emergency department, and adverse events.

RESULTS

• They enrolled 213 patients in each group. 17% (37 patients) in control group and 43% (93 patients) in study group achieved sinus rhythm (impressive odd ratio of 3.7, 95% CI 2.3-5.8, p<0.0001) with no reported adverse effects.

• Use of adenosine was significantly lower in the modified Valsalva manoeuvre group than in the standard Valsalva manoeurve group.

• Interestingly only four patients had recurrence of supraventricular tachycardia requiring further treatment in the emergency department.

TIME FRAME

433 participants enrolled between Jan 11, 2013, and Dec 29, 2014.

FINER

Feasibility

Yes. Enables a safe, effective and non-pharmacological treatment of SVT.

May essentially prevent hospitalization in pre-hospital setting with causing additional harm to patient.

Interesting

Yes

Novel

Yes(combined approach is new)

Ethical

Yes

Relevant

Yes(Easy, rapid, no harm method)

 

STRENGTH

164 different clinicians did the same procedure in different time, so significant easy of reproducibility.

WEAKNESS

Patients enrolled >18 years. It would have been beneficial if the enrollment included study population of lower age group also.

 

                                                                                                                                                                                       Study evaluated with PICOT & FINER criteria