Department of Emergency Medicine, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK.
Department of Emergency Medicine, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK.
Lancet. 2015 Oct 31;386(10005):1747-53. doi: 10.1016/S0140-6736(15)61485-4. Epub 2015 Aug 24.
The Valsalva manoeuvre is an internationally recommended treatment for supraventricular tachycardia, but cardioversion is rare in practice (5-20%), necessitating the use of other treatments including adenosine, which patients often find unpleasant. We assessed whether a postural modification to the Valsalva manoeuvre could improve its effectiveness.
We did a randomised controlled, parallel-group trial at emergency departments in England. We randomly allocated adults presenting with supraventricular tachycardia (excluding atrial fibrillation and flutter) in a 1:1 ratio to undergo a modified Valsalva manoeuvre (done semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain), or a standard semi-recumbent Valsalva manoeuvre. A 40 mm Hg pressure, 15 s standardised strain was used in both groups. Randomisation, stratified by centre, was done centrally and independently, with allocation with serially numbered, opaque, sealed, tamper-evident envelopes. Patients and treating clinicians were not masked to allocation. The primary outcome was return to sinus rhythm at 1 min after intervention, determined by the treating clinician and electrocardiogram and confirmed by an investigator masked to treatment allocation. This study is registered with Current Controlled Trials (ISRCTN67937027).
We enrolled 433 participants between Jan 11, 2013, and Dec 29, 2014. Excluding second attendance by five participants, 214 participants in each group were included in the intention-to-treat analysis. 37 (17%) of 214 participants assigned to standard Valsalva manoeuvre achieved sinus rhythm compared with 93 (43%) of 214 in the modified Valsalva manoeuvre group (adjusted odds ratio 3·7 (95% CI 2·3-5·8; p<0·0001). We recorded no serious adverse events.
In patients with supraventricular tachycardia, a modified Valsalva manoeuvre with leg elevation and supine positioning at the end of the strain should be considered as a routine first treatment, and can be taught to patients.
National Institute for Health Research.
瓦尔萨尔瓦动作是一种国际推荐的治疗室上性心动过速的方法，但实际上电复律很少见（5-20%），这就需要使用其他治疗方法，包括腺苷，而患者通常会觉得很不舒服。我们评估了对瓦尔萨尔瓦动作进行体位修正是否可以提高其疗效。
我们在英国的急诊室进行了一项随机对照、平行组试验。我们将患有室上性心动过速（不包括心房颤动和扑动）的成年人以 1:1 的比例随机分配，进行改良的瓦尔萨尔瓦动作（半卧位，在瓦尔萨尔瓦应变结束时立即仰卧位和被动抬腿）或标准的半卧位瓦尔萨尔瓦动作。两组均使用 40mmHg 压力、15s 标准化应变。按中心分层进行中央和独立的随机分组，使用编号、不透明、密封、防篡改的信封进行分配。患者和治疗临床医生对分组不知情。主要结局是干预后 1 分钟内恢复窦性节律，由治疗临床医生和心电图确定，并由对治疗分配不知情的研究者确认。这项研究在 Current Controlled Trials （ISRCTN67937027）注册。
我们于 2013 年 1 月 11 日至 2014 年 12 月 29 日期间纳入了 433 名参与者。排除 5 名参与者的第二次就诊，每组 214 名参与者纳入意向治疗分析。在标准瓦尔萨尔瓦动作组中，37 名（17%）参与者达到窦性节律，而在改良瓦尔萨尔瓦动作组中，93 名（43%）参与者达到窦性节律（调整后的优势比 3.7[95%CI 2.3-5.8;p<0.0001]）。我们没有记录到严重不良事件。
对于患有室上性心动过速的患者，应考虑在应变结束时进行腿部抬高和仰卧位的改良瓦尔萨尔瓦动作作为常规的一线治疗方法，并且可以教给患者。
英国国家健康研究所。
