Modified Valsalva Maneuver for SVT

Chief Complaint:

SVT

HPI:

Patient is a 49-year-old male with history of prior episodes of SVT and HTN.  He stated that over the past 5 years he’s had approximately one episode every 6 months.  He stated that a cardiologist instructed him that he should have an ablation that he likely has an accessory pathway however the patient is afraid of procedures and did not want to proceed. Immediately prior to arrival patient did have 2 beers and jumped into some cold stream water.  He states immediately after that he felt like he was in SVT with racing heart and lightheadedness. He denied any chest pain, shortness of breath or chest tightness. Stated in now way different than prior SVT episodes. Also, prior to arrival tried carotid massage and stated he always needs medication to slow his heart.

Pertinent Exam Findings:

Tachycardia

Diagnostic Studies:

EKG with SVT, BMP unremarkable

ED Course:

Upon arrival the patient was placed on a monitor and found to be in SVT. RN staff was instructed to pull adenosine and hang NS. While waiting for this, the patient attempted a valsalva maneuver by blowing into a 10cc syringe. Nothing happened. The modified valsalva maneuver then resulted in conversion to NSR and shortly after the RN returned with adenosine, which was no longer needed.

No troponin was obtained

Explanation:

Modified Valsalva Maneuver for SVT diagram

During the “strain phase” (A.) the patient is placed in high Fowlers, given a 10 ml syringe, and encouraged to blow continuously into the syringe, displacing the plunger, for approximately 15 seconds. During the “relaxation phase” (B.) the patient is laid supine and the legs are manually elevated.

High Yield Points:

In the REVERT Trial the standard technique returned 17% of patients to sinus rhythm, whereas the modified technique returned 43% of patients to sinus rhythm — more than doubling the effectiveness

Do elevated troponins during SVT predict the presence of CAD?

  • 12 – 48% of patients have elevated troponins after SVT [1] [2]
  • Having a known history of CAD is more likely to lead to troponin elevation than not having a history of CAD (62% vs 43%) [1]
  • There is no difference in the diagnosis of CAD compared to patients with negative troponins
  1. Low risk, prior SVT, feels good after conversion, then NO CARDIAC ENZYMES and outpatient f/u
  2. Intermediate to high risk, then DO get CARDIAC ENZYMES; If neg, outpatient follow up

References

R.N. Bukkapatnam, M. Robinson, S. Turnipseed, D. Tancredi, E. Amsterdam, and U.N. Srivatsa, “Relationship of myocardial ischemia and injury to coronary artery disease in patients with supraventricular tachycardia.”,The American journal of cardiology, 2010.http://www.ncbi.nlm.nih.gov/pubmed/20643248

M. Dorenkamp, M. Zabel, and C. Sticherling, “Role of coronary angiography before radiofrequency ablation in patients presenting with paroxysmal supraventricular tachycardia.”,Journal of cardiovascular pharmacology and therapeutics, 2007.http://www.ncbi.nlm.nih.gov/pubmed/17562784

    3. Appelboam A, Reuben A, Mann C et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. The Lancet. 2015;386(10005):1747-175

 

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