From the Guidelines
The Valsalva maneuver is recommended as the first-line intervention for acute treatment of supraventricular tachycardia (SVT) in patients with orthodromic AVRT, and it should be performed with the patient in the supine position for 10 to 30 seconds, equivalent to at least 30 mm Hg to 40 mm Hg 1.
Key Points
- The Valsalva maneuver is a breathing technique that creates increased intrathoracic pressure, which can help stimulate the vagus nerve and slow the heart rate.
- It is used to treat SVT, equalize pressure in the ears during flying or diving, assess autonomic nervous system function, and evaluate for certain heart conditions.
- The physiological mechanism of the Valsalva maneuver involves four phases: increased intrathoracic pressure reducing venous return to the heart, decreased cardiac output, increased sympathetic activity when pressure is released, and a temporary blood pressure overshoot.
- While generally safe, the Valsalva maneuver should be avoided by people with certain heart conditions, glaucoma, or recent eye surgery as it can temporarily increase blood pressure and intraocular pressure.
- The practice of applying pressure to the eyeball is potentially dangerous and has been abandoned 1.
Recommendations
- Vagal maneuvers, including the Valsalva maneuver and carotid sinus massage, are recommended for acute treatment in patients with orthodromic AVRT 1.
- Adenosine is recommended for acute treatment in patients with orthodromic AVRT when vagal maneuvers are ineffective or not feasible 1.
- Synchronized cardioversion is recommended for acute treatment in hemodynamically unstable patients with AVRT when vagal maneuvers or adenosine are ineffective or not feasible 1.
Important Considerations
- The Valsalva maneuver should be performed with caution in patients with certain medical conditions, such as glaucoma or recent eye surgery.
- Patients should be educated on how to perform the Valsalva maneuver correctly to avoid complications.
- The Valsalva maneuver is not a substitute for medical treatment, and patients with SVT should seek medical attention if symptoms persist or worsen.
From the Research
Valsalva Manoeuvre
- The Valsalva manoeuvre is a non-invasive technique used to restore normal sinus rhythm in patients with supraventricular tachycardia (SVT) by increasing intrathoracic pressure and stimulating baroreceptor activity 2, 3, 4.
- The effectiveness of the Valsalva manoeuvre in terminating SVT has been studied in several randomised controlled trials, with varying results 2, 3, 4.
- A study published in 2013 found that the Valsalva manoeuvre had a reversion rate of 45.9% and 54.3% in two laboratory studies, and 19.4% in a clinical study 2.
- A 2021 systematic review and meta-analysis found that the modified Valsalva manoeuvre had a significantly higher success rate for reconversion to sinus rhythm compared to the standard Valsalva manoeuvre in patients with SVT 3.
- The Valsalva manoeuvre has also been used as a bedside "biomarker" for heart failure, with studies demonstrating a significant correlation between the cardiovascular response to the Valsalva manoeuvre and invasively measured ventricular filling pressures in patients with heart failure 5.
- A standardized goal-directed Valsalva manoeuvre has been shown to be an effective method for assessing inducible left ventricular outflow tract obstruction in hypertrophic cardiomyopathy 6.
Uses of the Valsalva Manoeuvre
- Restoring normal sinus rhythm in patients with supraventricular tachycardia (SVT) 2, 3, 4.
- Evaluating volume status in patients with heart failure 5.
- Assessing inducible left ventricular outflow tract obstruction in hypertrophic cardiomyopathy 6.