Background: SVTs are commonly seen in the ED. Chemical cardioversion often takes several minutes to initiate because we have to get IV access and medication ready.  During this time, we can attempt some valsava maneuvers to cardiovert stable patients. Current valsava maneuvers have shown low efficacy 5-20%. The REVERT trial compared the standard Valsava to a modified Valsava.

Modified Valsava:

Step 1: 15 seconds of blowing into a syringe while sitting semi-recumbent

Step2: 15 seconds with legs lifted at 45 degrees while lying fully supine

Study Design:

  • Multicenter, Randomized Controlled, Parallel-Group Trial in 10 emergency departments in England
  • 428 patients with SVT included in primary analysis
  • Exclusion: Afib and Aflutter, sBP <90mmHg


Standard Valsalva Modified Valsalva
Return to Normal Sinus Rhythm at 1 min 17% (37/214) 43% (93/214 ) p <0.0001, NNT = 3
Use of Adenosine


69% (148/214) 50% (108/214) p = 0.0002
Any Adverse Event 4% (8/214) 6% (13/214) No Statistically Significant



Take home point:

If the patient with SVT is relatively young and stable, we should try this maneuver while waiting for adenosine. This is zero cost and well tolerated by patients.


  • Appelboam, A., et al. Postural modification to the standard Valsalva maneuver for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet (London, England) 2015;386(10005):1747-1753.
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