Tachycardia: Valsalva manoeuvre was not clearly better than carotid sinus massage.

Clinical bottom line (level 1b-)

  1. Patients with supraventricular tachycardia who performed the Valsalva manoeuvre, had no clear difference in treatment success than those given carotid sinus massage.
Lim et al: Annals of Emergency Medicine 1998; 31 (1): 30-35
Expires August 2004

The study

Unblinded unconcealed randomised trial with intention-to-treat
Setting: general hospital, Singapore

148 patients (aged range 10 to 90 years; mean 47, 57% female) supraventricular tachycardia

Excluded if
  • <10 years old
  • atrial flutter
  • atrial fibrillation
  • sinus tachycardia
  • haemodynamically unstable (signs of poor cerebral perfusion, pulmonary oedema or unstable angina)
  • contraindications for carotid sinus massage (history of transient ischaemic attack, cerebrovascular accident or presence of carotid bruit by direct auscultation)
  • sick sinus syndrome
  • ventricular tachycardia with left axis deviation and right bundle branch block


    • Control Group: (n = 62, 62 analysed): Valsalva manoeuvre- blowing into mouthpiece connected by a 6 inch tube to a sphygmomanometer. Patients were required to reach a pressure of 40 mmHg and sustain it for 30 seconds.
    Experimental Group: (n = 86, 86 analysed): carotid sinus massage- patient was in supine position with head tilted to the opposite side, the carotid sinus was located and finger pressure with a massaging motion in an upward an downward direction was applied posteriorly and medially to compress the carotid sinus between the examiner's fingers and the patients's cervical vertebrae for 10 seconds.
    Valsalva manoeuvre was supervised by an emergency physician or medicine resident. Carotid sinus massage was performed by physician or resident under supervision of physician. If tachycardia was not converted by vagal manoeuvres, patients were managed with pharmacotherapy or synchronised electrical cardioconversion at the discretion of the attending physician. Intravenous calcium channel blockers were used if patients were haemodynamically stable. Synchronised electrical cardioversion was used in patients who were haemodynamically unstable.
    100% followed for ?
    Outcome notes:
    • treatment success with initial vagal technique : tachycardia conversion

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNH
    (95% CI)
    treatment success with initial vagal technique unknown 12
    (19.4%)    		 9
    (10.5%)    		 46%
    (-20% to 76%)    		 8.89%
    (-2.88% to 20.7%)    		 11
    (NNT = 35 to infinity;
    NNH = 5 to infinity)

    Comments

    1. The study was too small to show a clear difference between the two treatments.
    2. The allocation concealment technique may have been very poor (random order of cards in envelopes).
    3. If the initial vagal technique did not work, the patient was given the alternative method. As the alternative, the Valsalva manoeuvre was successful in 13 out of 77 patients, and carotid sinus massage was successful in 7 out of 50.

    Citation

    1. Lim SH, Anantharaman V, Teo WS, et al: Comparison of treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage. Annals of Emergency Medicine 1998; 31 (1): 30-35
    Contributor: Clare Wotton and Bob Phillips, August 1999
    Reviewer:

    Clinical Question.
    Patient supraventricular tachycardia
    Intervention or Exposure Valsalva manoeuvre
    Comparison carotid sinus massage
    Outcome termination of spontaneous supraventricular tachycardia