A review presentation of the REVERT Trial, published in the Lancet medical journal in 2015. This study examines the use of a modification to the classic Valsalva technique in order to improve outcomes for patients presenting with supraventricular tachycardia. Note: Note: uploading to SlideShare causes disruption of slide layout, creating text overlap. The line in slide 2 which is obscured by the ECG reads "Potential increase in length of asystole in patients on certain drugs, e.g. carbamazepine, dipyridamole - reduce initial dose to 3mg" Original layout visible on download. Sources for all imagery and sources listed in references section where possible. I do not claim ownership of any images or graphics. Slides for educational purposes only, and should not replace clinical judgement. No monetary gain was made for this work.

1. Journal Review:
REVERT Trial
(Lancet, 2015)
Dr. Robert Ferris

2. Background
 In patients presenting with supraventricular tachycardia
(SVT), the Valsalva manoeuvre has long been
recommended as the initial treatment
◦ increases intrathoracic pressure leading to slowing of the heart
rate, often causing spontaneous cardioversion back to Normal
Sinus Rhythm (NSR)
 Standard Valsalva is effective in roughly 5-20% of patients
 IV adenosine (6mg push + 20mL NaCL 0.9% flush) is next
step, but has side-effects and interactions:
◦ “Sense of impending doom”: briefly stops AV conduction (transient
asystole)
◦ Bronchospasm (caution in patients with pulmonary disease, e.g.
COPD)
◦ Potential increase in length of asystole in patients on certain drugs,
e.g. carbamazepine, dipyridamole - reduce initial dose to 3mg

3. Randomised Evaluation of Modified
Valsalva Effectiveness in Re-entrant
Tachycardias (REVERT)
 Investigation to determine whether modification to
the classic Valsalva technique could improve
incidence of cardioversion, without the use of
adenosine

4. Modified Valsalva
 Method involves lying patient supine and elevating their
legs immediately following 15 second strain (target
40mmHG on manometer)
 Designed to increase relaxation phase venous return,
and improve vagal stimulation
 Requires only a 10mL syringe, and designed to be
simple to perform and easy to teach to patients

5. Methodology
 Run from January 2013 – April 2015
 Randomised controlled, parallel group trial
 Conducted across ten emergency departments
(two teaching hospitals and eight general hospitals)
across England
 Patients with suspected SVT were identified at
triage, and randomly assigned to control (standard
Valsalva) or intervention (modified Valsalva) groups
on a 1:1 ratio, following 12-lead ECG
 Exclusion criteria included:
◦ patients unable to perform manoeuvre
◦ patients with A.Fib/flutter
◦ unstable patients with SBP<90mmHg

6. Outcome Measures
Primary
 Return to NSR at ≤1 minute
◦ Post-treatment ECGs were reviewed by an independent
cardiologist, blinded to treatment allocation groups
Secondary
 Incidence of adenosine use
 Number of hospital admissions
 Length of ED stay
 Incidence of adverse events

7. Results

8. Results
 The primary outcome of reversion to NSR was
achieved in 43% of intervention patients vs. 17% of
control patients
 Adenosine use was required in 19% fewer instances
for intervention (50%) vs. control (69%) patients
 No serious adverse events were reported: non-serious
events were slightly more common in the intervention
group vs. the control group (6% vs. 4%, respectively),
but this was not statistically significant. All adverse
events were self-limiting and required no additional
treatment.

9. Strengths and Limitations
 Statistically significant improvement in
patient outcomes with modified
technique
 No cost
 Simple intervention, which can be
performed in outpatient settings or in a
patient’s own home
 Investigators not blinded to groups
 No significant reduction to hospital
admissions (often attributed to other
comorbidities)

10. Conclusion
 In patients presenting with SVT, a
modified Valsalva manoeuvre is a
simple, cost-free technique which
should be performed as a first-line
intervention prior to
pharmaceutical/electrical
cardioversion.

11. References
1. Appelboam, A., Reuben, A., Mann, C., Gagg, J., Ewings, P., Barton, A.,
Lobban, T., Dayer, M., Vickery, J., Benger, J. (2015), ‘Postural
modification to the standard Valsalva manoeuvre for emergency
treatment of supraventricular tachycardias (REVERT): a randomised
controlled trial’, Lancet 386: 1747-1753
2. Rezaie, S. (2015), ‘The REVERT Trial: A Modified Valsalva Maneuver to
Convert SVT’, Rebel EM, accessed at https://rebelem.com/the-revert-
trial-a-modified-valsalva-maneuver-to-convert-svt/ on 26/10/2020
3. Marks, P., Lewis, D. (2019), ‘Modified Valsalva maneuver in the treatment
of SVT – REVERT Trial’, Saint John Regional Hospital Department of
Emergency Medicine, accessed at http://sjrhem.ca/modified-valsalva-
maneuver-in-the-treatment-of-svt-revert-trial/ on 26/10/2020
4. The Lancet (2015), ‘Modified Valsalva manoeuvre for supraventricular
tachycardia’, YouTube, accessed at
https://www.youtube.com/watch?v=8DIRiOA_OsA on 26/10/2020
5. American Heart Association (2016), ‘Advanced Cardiovascular Life
Support Provider Manual’, Original English Edition: 139-143
6. Burns, E. (2019), ‘Supraventricular Tachycardia (SVT)’, Life in the Fast
Lane, accessed at https://litfl.com/supraventricular-tachycardia-svt-ecg-
library/ on 26/10/2020
7. ‘Supraventricular tachycardia’, Wikipedia, accessed at
https://en.wikipedia.org/wiki/Supraventricular_tachycardia on 26/10/2020