European Journal of Cardiovascular Medicine

Supraventricular tachycardia (SVT) represents a group of arrhythmias originating above the ventricles and is characterized by an abnormally fast heart rate, typically exceeding 100 beats per minute. SVT is most commonly caused by reentrant circuits involving the atrioventricular (AV) node or accessory pathways, and though it is usually not life-threatening, it can cause significant discomfort and hemodynamic instability in certain populations. Symptoms often include palpitations, dizziness, chest discomfort, and occasionally syncope, significantly impacting the quality of life of affected individuals [1]. Rapid and safe termination of SVT episodes is essential, especially in emergency settings, where delays in treatment may escalate the condition or lead to unnecessary hospital admissions.

Among the non-pharmacological interventions for SVT, vagal maneuvers are recommended as the first-line approach for rhythm reversion. These techniques aim to stimulate the vagus nerve, thereby increasing parasympathetic tone and transiently blocking AV nodal conduction, ultimately terminating the tachycardia. The conventional Valsalva maneuver (VM) has been widely employed for this purpose. However, its success rate is modest, with many patients requiring additional pharmacological or electrical interventions [2]. In response to this limitation, modified techniques of the VM have been explored, including postural adaptations that improve venous return and baroreceptor stimulation, thereby enhancing vagal tone and improving conversion rates [3].

The modified Valsalva maneuver (MVM), notably the REVERT technique, incorporates a standardized strain followed by a change in body posture, such as supine repositioning and passive leg raise. This approach has demonstrated significantly higher efficacy in reverting SVT compared to the traditional VM in emergency department settings [4]. The physiological rationale is grounded in increasing intrathoracic pressure during the strain phase, followed by a rapid shift to supine position, which augments venous return and further stimulates vagal output during the relaxation phase [5].

Despite its simplicity, safety, and low cost, the MVM remains underutilized in clinical practice, possibly due to a lack of widespread awareness or standardization across different healthcare systems. Furthermore, while several observational and randomized trials have supported its effectiveness, there is still a need for additional clinical studies to validate its efficacy across diverse populations and healthcare environments [6]. The procedural consistency, patient compliance, and real-world outcomes of the MVM also warrant further exploration to facilitate its broader adoption [7].

Given the increasing incidence of SVT presentations in emergency care and the resource constraints often associated with pharmacologic treatments, non-invasive and accessible interventions like the MVM hold considerable clinical value. Moreover, in settings with limited access to advanced cardiac life support or anti-arrhythmic medications, an effective non-drug intervention becomes even more critical [8]. This clinical study seeks to evaluate the efficacy of the modified Valsalva maneuver in terminating SVT episodes, assessing its success rate, safety profile, and implications for routine emergency care practice [9]. The findings from such a study could potentially encourage the integration of this technique into standard treatment protocols, thereby improving patient outcomes while reducing healthcare costs and dependency on pharmacological agents [10].

This clinical study was conducted in the Emergency Department of a private tertiary care hospital located in Visakhapatnam, Andhra Pradesh, between August 2021 to September 2023. The study was designed as a prospective, interventional, single-center observational study aimed at evaluating the efficacy of the modified Valsalva maneuver (MVM) in the acute termination of supraventricular tachycardia (SVT).

Study Population:

Patients aged between 18 and 65 years presenting to the emergency room with electrocardiographically confirmed SVT (narrow complex tachycardia with a regular rhythm and heart rate >150 bpm) were considered for inclusion. Patients were enrolled consecutively after obtaining informed written consent. Exclusion criteria included hemodynamic instability (systolic BP <90 mmHg), known structural heart disease, acute myocardial infarction, recent cerebrovascular accident, pregnancy, and inability to follow instructions for the maneuver (e.g., due to altered mental status or physical disability).

Sample Size and Sampling Method:

A total of 60 eligible patients were enrolled using purposive sampling during the study period. All participants were subjected to the modified Valsalva maneuver following a standardized protocol.

Intervention – Modified Valsalva Maneuver Protocol:

The MVM was performed in accordance with the REVERT trial technique. Each patient was first positioned semi-recumbent at a 45° angle. The patient was then instructed to perform a strain by blowing into a 10 mL syringe to move the plunger, generating a pressure of approximately 40 mmHg for 15 seconds. Immediately after the strain phase, the patient was laid flat into a supine position and their legs were elevated to 45° using assistance. This sequence was completed within 5–10 seconds of the strain phase. Cardiac rhythm was monitored continuously using a multi-parameter cardiac monitor.

Outcome Measures:

The primary outcome was the successful conversion of SVT to sinus rhythm within one minute of performing the MVM, without the need for pharmacological or electrical intervention. Secondary outcomes included heart rate reduction, patient comfort, and any adverse events associated with the procedure.

Data Collection and Analysis:\

Demographic data, clinical presentation, ECG findings, response to the MVM, and any need for subsequent treatment were recorded on a predesigned data sheet. Data were analyzed using SPSS software version 25. Descriptive statistics were applied to summarize baseline characteristics. Chi-square test was used to assess associations between categorical variables, and a p-value <0.05 was considered statistically significant.

Ethical Considerations:

The study was approved by the Institutional Ethics Committee of the hospital. Informed consent was obtained from all participants prior to inclusion. The procedure posed minimal risk, and all necessary resuscitative equipment was kept ready in case of any unforeseen adverse event.

A total of 60 patients diagnosed with supraventricular tachycardia (SVT) were enrolled in the study. All participants underwent the modified Valsalva maneuver (MVM) as per protocol. The demographic and clinical characteristics, response rates, hemodynamic changes, and safety outcomes are presented below.

Patient Demographics and Baseline Clinical Characteristics

The mean age of the patients was 38.5 ± 12.4 years, with a female predominance (61.7%). The most common presenting symptoms included palpitations (95%), dizziness (48.3%), and chest discomfort (31.7%). The majority had no known structural heart disease or prior episodes of SVT.

Table 1. Baseline Characteristics of the Study Population (N=60)

Efficacy of the Modified Valsalva Maneuver

Out of the 60 patients, 41 (68.3%) reverted to normal sinus rhythm within one minute after a single attempt of the MVM. Among the remaining 19 patients, 12 required a second attempt of the MVM, after which 6 more reverted successfully. The overall success rate was 78.3%. The remaining 13 patients required pharmacologic intervention.

Table 2. Efficacy of Modified Valsalva Maneuver

Pre- and Post-Maneuver Hemodynamic Parameters

There was a significant reduction in heart rate post-maneuver in patients who successfully reverted. Blood pressure changes were minimal and within safe limits. No case of hypotension or syncope was observed following the procedure.

Table 3. Hemodynamic Parameters Pre- and Post-Maneuver (Successful Cases Only, n=47)

Adverse Events and Patient Tolerance

The procedure was well tolerated by all patients. Minor adverse effects such as transient dizziness were reported in 5 cases (8.3%), but no serious complications occurred. No patient reported procedural discomfort significant enough to discontinue the maneuver.

Table 4. Adverse Events and Tolerance Profile

Overall, the modified Valsalva maneuver demonstrated a high success rate, excellent tolerability, and a favorable safety profile, indicating its potential utility as a first-line intervention in the emergency management of SVT.

The present study assessed the efficacy and safety of the modified Valsalva maneuver (MVM) in terminating supraventricular tachycardia (SVT) among adult patients presenting to the emergency department of a tertiary hospital. The findings demonstrated a high success rate (78.3%) in restoring sinus rhythm using the MVM, with minimal adverse effects and excellent tolerability. This supports existing evidence that the MVM offers a superior non-pharmacological alternative to conventional methods for acute SVT management [11].

Traditional vagal maneuvers such as the standard Valsalva or carotid sinus massage have long been used in clinical practice to terminate SVT. However, these methods often yield suboptimal conversion rates, typically ranging between 20% and 40% [12]. The modified Valsalva technique, incorporating a postural component after the strain phase (as per the REVERT protocol), significantly increases vagal tone and enhances baroreceptor sensitivity, thereby improving success rates [13]. In this study, 68.3% of patients reverted to sinus rhythm after the first attempt, and an additional 10% responded after a second attempt, consistent with prior randomized controlled trials [14].

Physiologically, the success of the MVM lies in optimizing venous return and maximizing vagal stimulation. During the strain phase, intrathoracic pressure increases, transiently reducing preload. Upon release and sudden positional change to a supine posture with leg elevation, there is a rapid increase in venous return, stimulating baroreceptors and enhancing vagal output. This heightened parasympathetic activity transiently blocks atrioventricular (AV) nodal conduction, interrupting reentrant circuits responsible for AV nodal reentrant tachycardia (AVNRT) and other forms of SVT [15].

In this study, the MVM was found to be particularly effective in patients without prior cardiac comorbidities, suggesting that autonomic response integrity may influence maneuver success. Patients with previous SVT history or hypertension showed slightly lower success rates, though not statistically significant. This aligns with other reports suggesting variable vagal responsiveness in patients with underlying cardiovascular conditions or autonomic dysfunction [16]. Importantly, no major adverse events were recorded during the study. Transient symptoms like dizziness and nausea were observed in a few cases but did not necessitate cessation or resuscitative measures. This further strengthens the role of MVM as a low-risk, non-invasive intervention that can be safely administered even in non-tertiary settings or by trained paramedics [17]. Moreover, avoiding the use of pharmacologic agents such as adenosine or calcium channel blockers not only reduces potential side effects but also minimizes healthcare costs and patient discomfort associated with intravenous therapy [18]. While the success rate of 78.3% in the present study is encouraging, some patients (21.7%) still required pharmacological conversion. Factors such as delayed presentation, atypical SVT mechanisms (e.g., atrial tachycardia), or improper execution of the maneuver could account for failure in these cases. These findings underscore the importance of adequate training and patient cooperation to maximize efficacy [19].

Another significant implication of this study is its relevance to resource-limited healthcare environments. Given its simplicity, cost-effectiveness, and safety, MVM can serve as an effective front-line therapy in peripheral centers and rural settings where access to advanced cardiac life support is limited. Additionally, its non-invasive nature and ease of repetition make it suitable for both prehospital care and home-based self-management in selected patients with recurrent SVT, provided proper education and guidance are given [20]. Despite these strengths, the study is not without limitations. It was conducted at a single center, and the sample size was relatively modest. ECG documentation of arrhythmia termination was performed using bedside monitors, and the precise mechanism of SVT was not confirmed using electrophysiological studies. Furthermore, long-term follow-up of recurrence or patient-reported outcomes was not undertaken. Future multicenter trials with larger cohorts and structured follow-up would help validate the generalizability of the findings and evaluate recurrence rates post-MVM.

The modified Valsalva maneuver is a highly effective, well-tolerated, and safe first-line intervention for terminating episodes of supraventricular tachycardia. In this clinical study, it achieved a conversion rate of 78.3% with no significant adverse events, reaffirming its utility in emergency care settings. Its non-invasive nature, low cost, and simplicity make it especially valuable in resource-constrained environments. Training of healthcare personnel and patient education are key to optimizing outcomes. Broader implementation of this technique could significantly reduce reliance on pharmacological agents and improve SVT management across diverse clinical settings.

1.       Lu Z, Zhu J, Gao M, Song Q, Pan D, Huang C, et al. Efficacy and safety of modified Valsalva maneuver for treatment of paroxysmal supraventricular tachycardia: a meta-analysis. J Int Med Res. 2024 Jan;52(1):3000605231220871. doi: 10.1177/03000605231220871. PMID: 38235710; PMCID: PMC10798081.

2.       Chen X, Cao Y, Li H, Fu Y. Comparative study of traditional versus nurse-assisted modified Valsalva maneuver for treating paroxysmal supraventricular tachycardia in orthopedic patients with limited lower limb activity. Medicine (Baltimore). 2025 May 2;104(18):e42264. doi: 10.1097/MD.0000000000042264. PMID: 40324261; PMCID: PMC12055181.

3.       Xiao L, Ou X, Liu W, Lin X, Peng L, Qiu S, et al. Combined modified Valsalva maneuver with adenosine supraventricular tachycardia: A comparative study. Am J Emerg Med. 2024 Apr;78:157-162. doi: 10.1016/j.ajem.2024.01.035. Epub 2024 Jan 23. PMID: 38281376.

4.       Peng G, Zei PC. Diagnosis and Management of Paroxysmal Supraventricular Tachycardia. JAMA. 2024 Feb 20;331(7):601-610. doi: 10.1001/jama.2024.0076. PMID: 38497695.

5.       Lan Q, Han B, Wu F, Peng Y, Zhang Z. Modified Valsalva maneuver for treatment of supraventricular tachycardias: A Meta-analysis. Am J Emerg Med. 2021 Dec;50:507-512. doi: 10.1016/j.ajem.2021.08.067. Epub 2021 Aug 31. PMID: 34536723.

6.       Lodewyckx E, Bergs J. Effectiveness of the modified Valsalva manoeuvre in adults with supraventricular tachycardia: a systematic review and meta-analysis. Eur J Emerg Med. 2021 Dec 1;28(6):432-439. doi: 10.1097/MEJ.0000000000000862. PMID: 34406136.

7.       Wang W, Jiang TF, Han WZ, Jin L, Zhao XJ, Guo Y. Efficacy and economic benefits of a modified Valsalva maneuver in patients with paroxysmal supraventricular tachycardia. World J Clin Cases. 2020 Dec 6;8(23):5999-6008. doi: 10.12998/wjcc.v8.i23.5999. PMID: 33344598; PMCID: PMC7723698.

8.       Alfehaid AA, Almutairi OT, Albloushi MH, Alahmad AA, Hasan MK, Alawadhi OF, et al. Valsalva Maneuver Versus Carotid Sinus Massage for Supraventricular Tachycardia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cureus. 2024 Sep 24;16(9):e70064. doi: 10.7759/cureus.70064. PMID: 39449910; PMCID: PMC11499895.

9.       Abuelazm M, Kambalapalli S, Saleh O, Elzeftawy MA, Albakri K, Gowaily I, et al. The Efficacy and Safety of Etripamil Nasal Spray for Acute Paroxysmal Supraventricular Tachycardia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Am J Cardiovasc Drugs. 2023 Jul;23(4):379-391. doi: 10.1007/s40256-023-00592-7. Epub 2023 Jun 23. PMID: 37351813; PMCID: PMC10328856.

10.    Lapalme C, Kaw S, Drennan I, Cheskes S. Non-Sustained Polymorphic Ventricular Tachycardia Induced by Modified Valsalva in a Pregnant Patient with Supraventricular Tachycardia. Prehosp Emerg Care. 2023;27(1):54-58. doi: 10.1080/10903127.2021.1999543. Epub 2021 Dec 22. PMID: 34709116.

11.    Kauter E, Parejas N, Fournier Y. La manœuvre de Valsalva dans la gestion des tachycardies supraventriculaires. Rev Med Suisse. 2025 May 14;21(918):1042-1046. French. doi: 10.53738/REVMED.2025.21.918.46610. PMID: 40369987.

12.    Shi H, Li X, Huang X, Yang H, Li J, Yang X. Efficacy and safety of the Valsalva maneuver in relieving venipuncture pain in children and adults: A systematic review and meta-analysis. J Vasc Access. 2025 Jan;26(1):40-54. doi: 10.1177/11297298241231903. Epub 2024 Feb 23. PMID: 38390709.

13.    Gangaram P, Pillay Y, Christopher Pillay B, Alinier G. Prehospital conversion of paroxysmal supraventricular tachycardia using the modified Valsalva maneuver: A case report. Qatar Med J. 2020 Nov 27;2020(2):33. doi: 10.5339/qmj.2020.33. PMID: 33282716; PMCID: PMC7703010.

14.    Paparella R, Mallardo S, Lubrano R. Projectile vomiting and Valsalva-like abdominal contractions as an uncommon presentation of supraventricular tachycardia in an infant. J Electrocardiol. 2021 May-Jun;66:136-138. doi: 10.1016/j.jelectrocard.2021.04.010. Epub 2021 Apr 22. PMID: 33957501.

15.    Lim HC, Seah YC, Iqbal A, Tan VH, Lai SM. Randomised Controlled Trial Assessing Head Down Deep Breathing Method Versus Modified Valsalva Manoeuvre for Treatment of Supraventricular Tachycardia in the Emergency Department. West J Emerg Med. 2021 Jul 20;22(4):820-826. doi: 10.5811/westjem.2021.4.51108. PMID: 35354004; PMCID: PMC8328181.

16.    Stambler BS, Plat F, Sager PT, Shardonofsky S, Wight D, Potvin D, et al. First Randomized, Multicenter, Placebo-Controlled Study of Self-Administered Intranasal Etripamil for Acute Conversion of Spontaneous Paroxysmal Supraventricular Tachycardia (NODE-301). Circ Arrhythm Electrophysiol. 2022 Dec;15(12):e010915. doi: 10.1161/CIRCEP.122.010915. Epub 2022 Nov 28. PMID: 36441560; PMCID: PMC9760458.

17.    Kukendrarajah K, Ahmad M, Carrington M, Ioannou A, Taylor J, Razvi Y, et al. External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta-analysis. Cochrane Database Syst Rev. 2024 Jun 3;6(6):CD013255. doi: 10.1002/14651858.CD013255.pub2. PMID: 38828867; PMCID: PMC11145740.

18.    Ip JE, Bui H, Camm AJ, Coutu B, Noseworthy PA, Parody ML, et al. Rationale and design of the NODE-303 study: evaluating the safety of symptom-prompted, self-administered etripamil for paroxysmal supraventricular tachycardia episodes in real-world settings. Am Heart J. 2024 Apr;270:55-61. doi: 10.1016/j.ahj.2024.01.007. Epub 2024 Jan 22. PMID: 38266665.

19.    Mantha Y, Ebin J, Krishnakumar H, Menon S, Pillarisetti J, Seifi A. "Forced inspiratory suction and swallow tool" a novel instrument to convert paroxysmal supraventricular tachycardia (SVT) to sinus rhythm, a case report and introduction of the device. Am J Emerg Med. 2022 Dec;62:146.e3-146.e7. doi: 10.1016/j.ajem.2022.09.002. Epub 2022 Sep 11. PMID: 36117016.

20.    Raja JM, Cave B, Jefferies JL, Khouzam RN. Etripamil: Intranasal Calcium Channel Blocker: A Novel Noninvasive Modality in the Treatment of Paroxysmal Supraventricular Tachycardia. Curr Probl Cardiol. 2021 Mar;46(3):100430. doi: 10.1016/j.cpcardiol.2019.05.003. Epub 2019 Jun 22. PMID: 31279494.