Volume 2020, Issue 2
  • ISSN: 0253-8253
  • EISSN: 2227-0426


The modified Valsalva maneuver (MVM) has never before been performed in the prehospital setting by the Hamad Medical Corporation Ambulance Service (HMCAS) clinicians in the State of Qatar. Currently, their clinical practice guidelines (CPG) prescribe the vagal maneuver (VM) using a 10 cc syringe as first-line therapy for patients presenting with symptomatic paroxysmal supraventricular tachycardia (pSVT). The effectiveness of the MVM in terminating pSVT compared to the traditional VM is well documented, although prehospital studies in this area are lacking. In this case, a generally healthy, 47-year-old male migrant worker presented with new-onset symptomatic pSVT, which was successfully terminated by a MVM after initial failed attempts of the traditional VM. The MVM is a postural technique performed by initially placing the patient in a semirecumbent position. The patient is then encouraged to blow into a manometer to achieve a 40 mmHg intrathoracic pressure for 15 seconds. Once the 40 mmHg intrathoracic pressure is achieved, the patient is repositioned supine, and their legs are raised passively to 45 degrees for 15 seconds. The patient is then returned to the semirecumbent position for 45 seconds before cardiac rhythm reassessment. The MVM has shown to have an increased termination rate of pSVT with no documented serious adverse events. The MVM can be performed in a time-effective manner and is cost effective as intravenous (IV) cannulation is not required. The prevention of adenosine-associated transient asystole is prevented. It is recommended that ambulance services consider the inclusion of the MVM in their CPGs for the treatment of new-onset pSVT.


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  1. Orejarena LA, Vidaillet H, DeStefano F, Nordstrom DL, Vierkant RA, Smith PN, et al. Paroxysmal supraventricular tachycardia in the general population. J Am Coll Cardiol. 1998;31(1):150–7 .
  2. Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. J Am Coll Cardiol. 2016;67(13):e27–e115 .
  3. Al-Zaiti SS, Magdic KS. Paroxysmal supraventricular tachycardia: pathophysiology, diagnosis, and management. Crit Care Nurs Clin. 2016;28(3):309–16 .
  4. Katritsis DG, Boriani G, Cosio FG, Hindricks G, Jais P, Josephson ME, et al. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). EP-Europace. 2017;19(3):465–511 .
  5. Colucci RA, Silver MJ, Shubrook J. Common types of supraventricular tachycardia: diagnosis and management. Am Fam Physician. 2010;82(8):942–52 .
  6. Kamel H, Elkind MS, Bhave PD, Navi BB, Okin PM, Iadecola C, et al. Paroxysmal supraventricular tachycardia and the risk of ischemic stroke. Stroke. 2013:STROKEAHA. 113.001118 .
  7. Chen C, Tam TK, Sun S, Guo Y, Teng P, Jin D, et al. A multicenter randomized controlled trial of a modified valsalva maneuver for cardioversion of supraventricular tachycardias. Am J Emerg Med. 2019;Epub August 1 .
  8. Sohinki D, Obel OA. Current trends in supraventricular tachycardia management. The Ochsner J. 2014;14(4):586–95 .
  9. HMCAS. Clinical practice guidelines. In: Hamad Medical Corporation Ambulance Services, editor. 2020 ed. Qatar: Hamad Medical Corporation Ambulance Service; 2020 .
  10. Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, et al. Postural modification to the standard valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015;386(10005):1747-53 .
  11. Smith G, Boyle MJ. The 10 mL syringe is useful in generating the recommended standard of 40 mmHg intrathoracic pressure for the valsalva manoeuvre. Emerg Med Australas. 2009;21(6):449–54 .
  12. Taylor DM, Wong LF. Incorrect instruction in the use of the valsalva manoeuvre for paroxysmal supra-ventricular tachycardia is common. Emerg Med Australas. 2004;16(4):284–7 .
  13. Mohammad AM, Saeed MS, Migliore F. Effectiveness of the modified valsalva maneuver in the emergency management of supraventricular tachycardia. Medical Journal of Babylon. 2019;16(2):104–7 .
  14. Tachycardia Narrow Complex Clinical Practice Guidelines. In: Queensland Ambulance Service, editor. Australia: Queensland Government; 2017 .
  15. Walker S, Cutting P. Impact of a modified valsalva manoeuvre in the termination of paroxysmal supraventricular tachycardia. Emerg Med J. 2010;27(4):287–91 .
  16. Smith GD, Fry MM, Taylor D, Morgans A, Cantwell K. Effectiveness of the valsalva manoeuvre for reversion of supraventricular tachycardia. The Cochrane Library. 2015; Cochrane Database Syst Rev. 2013;3 .
  17. Smith G. Management of supraventricular tachycardia using the Valsalva manoeuvre: a historical review and summary of published evidence. Eur J Emerg Med. 2012;19(6):346–52 .
  18. Appelboam A, Gagg J, Reuben A. Modified valsalva manoeuvre to treat recurrent supraventricular tachycardia: description of the technique and its successful use in a patient with a previous near fatal complication of DC cardioversion. Brit Med J. 2014;2014:bcr2013202699 .
  19. Rayburn D, Wagers B. Modified valsalva maneuver for pediatric supraventricular tachycardia. Pediatr Emerg Care. 2020;36(1):e8–e9 .
  20. Morley-Smith EJ, Gagg J, Appelboam A. Cardioversion of a supraventricular tachycardia (SVT) in a 7-year-old using a postural modification of the valsalva manoeuvre. Case Reports. 2017;2017:bcr2016218083 .
  21. Davis WD, Norris KC, Fiebig W. The modified valsalva maneuver for reversion of stable supraventricular tachycardia: lessons learned from the REVERT trial. Adv Emerg Nurs J. 2019;41(3):192–7 .
  22. Pandya A, Lang E. Valsalva maneuver for termination of supraventricular tachycardia. Ann Emerg Med. 2015;65(1):27–9 .
  23. Çorbacıoğlu S¸K, Akıncı E, Çevik Y, Aytar H, Öncül MV, Akkan S, et al. Comparing the success rates of standard and modified valsalva maneuvers to terminate PSVT: a randomized controlled trial. Am J Emerg Med. 2017;35(11):1662–5 .

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