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Efficacy of Valsalva Maneuvers Versus Drug Therapy in the Treatment of PSVT

Efficacy of Valsalva Maneuvers Versus Drug Therapy in the Treatment of PSVT. Beth Froelke MSIII. Outline. Patient Presentation Supraventricular Tachycardia What is it? Treatment Options Utility of vagal maneuvers in ED setting Underused Improper technique. Patient Presentation. Z.S.

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Efficacy of Valsalva Maneuvers Versus Drug Therapy in the Treatment of PSVT

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  1. Efficacy of Valsalva Maneuvers Versus Drug Therapy in the Treatment of PSVT Beth Froelke MSIII

  2. Outline • Patient Presentation • Supraventricular Tachycardia • What is it? • Treatment Options • Utility of vagal maneuvers in ED setting • Underused • Improper technique

  3. Patient Presentation • Z.S. • 48 year old Female • PMH: • Remote h/o SVT: “years” prior converted to NSR with drug; uncertain whether she had an echocardiogram in past; has had a couple brief instances of heart fluttering this year • Asthma; Hypothyroidism • Palpitations: • Performed Valsalva as instructed by cardiologist seen at OSH but did not stop palpitations • Has no PMD; no current cardiologist • We did not ask how vagal maneuvers were performed • No other presenting complaints

  4. Family History: non-contributory • Social History: non-smoker, no ETOH • ROS: negative (denies chest pain, SOB; lightheadedness) • Meds: none • Allergies: NKDA • PE: • BP 135/80; Pulse 190; RR 18; O2sat 98%RA • Anxious • Tachycardia

  5. Pretreatment ECG

  6. Paroxysmal Supraventricular Tachycardia Causes: • *Reentrant circuit at AV node (AVNRT) • Fast pathway with slow refractory and slow pathway with fast refractory period • Normal hearts; MI, pericarditis, valve disease • EKG: “pseudo” S wave II, III, aVF (retrograde P); short RP • Treatment options • Unstable: Cardioversion – 50 J • Stable • Vagal maneuvers • Adenosine, verapamil, Beta-blockers • Z.S. after receiving adenosine 6mg IV…

  7. Post-treatment ECG

  8. Z.S. • BP 117/66; HR 96; RR 18; O2sat 100%RA • Monitored • Labs: Cardiac enzymes (normal); BMP, CBC • Toprol XL 50mg po X 1 • Discharged to home • Toprol XL 50mg po qday • Instructions: see PMD for referral to cardiologist and EP study

  9. Vagal Maneuvers • Recommended first line for stable patients • Valsalva, carotid massage • Appropriate techniques • CM: Check for pulses and bruits bilaterally; 10 sec steady pressure on carotid of NDH • Valsalva: (Wong et al., 2004) • Expire against a closed epiglottis for 15 seconds • Pathophysiology

  10. What do we do in the ED? • Vagal maneuvers becoming more and more neglected as first line intervention than drug therapy • Efficacy of drug versus vagal maneuvers • Adenosine/verapamil more successful than vagal maneuvers • Taylor et al. (1999): retrospective • Valsalva: 1st line intervention 36.7%; success: 6.1% • Adenosine: 1st line intervention 32.7%; success: 68% • Sinus Massage: 1st line 26.5%; success 2% • Verapamil: 1st line 4.1%; Success 14% • Others studies have shown similar rates of success between verapamil and adenosine (DiMarco et al., 1990)

  11. Possible causes of failed conversion to NSR with Valsalva • Varied positions have varied results • Wong et al., 2004 • 65 healthy subjects; single blind; repeated-measures • 5 Valsalva positions: supine; supine with epigastric pressure; supine with legs raised, semi-recumbent, sitting • EKG: R-R interval changes with each maneuver • Results: supine and supine with epigastric >> supine with legs raised, semi-recumbent, sitting • Majority of studies assessing efficacy of Valsalva do not describe how it is performed

  12. Varied instruction by physicians • Taylor and Wong, 2004 • Small scale study (N=17 physicians): asked to describe how they would instruct a patient to perform VM in the case of SVT • 9.6% correctly described how to position patient • Most would place patient in sitting or semi-recumbent position

  13. Cost benefit • Side effects of drugs • Adenosine: flushing, chest pain/pressure, dizziness; serious reactions: asystole, arrhythmias • Side effects of vagal maneuvers • Valsalva: few side effects (transient lightheadedness) • Carotid massage: stroke, not generally recommended in older age, CVA risk patients • $$$: • Vagal maneuvers - FREE • Efficacy • Adenosine or Verapamil > Valsalva or CM

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