• Noor ul Hadi Cardiology Department, MTI, Mardan Medical College, Mardan
  • Asfandiyar 1Cardiology Department, MTI, Mardan Medical College, Mardan
  • Ikram ullah Lady Reading Hospital, Peshawar,
  • Syed Tahir Shah Kuwait teaching Hospital
  • Farooq Ahmad Khyber Teaching Hospital Peshawar
  • Abdur Rahman Cardiology Department, MTI, Mardan Medical College, Mardan
  • Mushataq Ahmad Professor of Cardiology and Head of Department MTI MMC MARDAN.



Background: Vagal Maneuver is an underutilized strategy for Cardioversion of Atrioventricular nodal reentrant tachycardia. The present study is an attempt to explore the effectiveness of this strategy. Methods: This comparative cross-sectional study was performed at the Department of Cardiology MTI MMC Mardan from the first January 2017 to 31 December 2019. Patients with Palpitations and having documented AVNRT on ECG were selected for this study. Patients were divided into two groups, i.e., Group A and Group B through envelope method. Patients in Group A were subjected to vagal maneuvers like carotid sinus massage, and Valsalva methods. Patients in Group B received injection verapamil 5 mg. Results: A sample size of 100 patients were enrolled. The mean age was 31 with 8.6SD. Male were 54% and females were 46%. The success rate of vagal maneuvers in group A was 36% (n=18), while in group B, it was 84% (n=42) for verapamil (36% vs 84%, p-value<0.001, highly significant). In group A, time for cardioversion in less than 2 minutes was 68%. While in group B, the time for cardioversion in less than two minutes was 12%. ( 68% vs 12%, p<0.001, highly significant).Cross over in Group A was 64%  (n=32) to verapamil. While in group B, this was 6% (n=3) to DC shock and 14% (n=7) to vagal maneuvers (64% vs 18%, p<0.001, highly significant.) Conclusion: Simple Valsalva Maneuvers and verapamil proved to be effective in cardioversion of SVT/AVNRT. Both are safe. Verapamil is more successful in cardioversion as compared to Valsalva maneuvers.

Author Biographies

Noor ul Hadi, Cardiology Department, MTI, Mardan Medical College, Mardan


Syed Tahir Shah, Kuwait teaching Hospital

Departement of Cardiology

Farooq Ahmad, Khyber Teaching Hospital Peshawar

Department of Cardiology

Abdur Rahman, Cardiology Department, MTI, Mardan Medical College, Mardan



Katritsis DG, Boriani G, Cosio FG, Hindricks G, Jais P, Josephson ME, et al. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). EP Europace. Eur Heart J 2018;39:1442–5.

Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C. The 2019 ESC guidelines for the management of patients with supraventricular tachycardia. Eur Heart J 2019;40:3812–3.

Lee KW, Badhwar N, Scheinman MM. Supraventricular tachycardia—part I. Curr Probl Cardiol 2008;33(9):467–546.

Orejarena LA, Vidaillet H Jr, DeStefano F, Nordstrom DL, Vierkant RA, Smith PN, et al. Paroxysmal supraventricular tachycardia in the general population. J Am Coll Cardiol 1998;31(1):150–7.

Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, et al. Postural modification to the standard Valsalva maneuver for emergency treatment of supraventricular tachycardias (REVERT): a randomized controlled trial. Lancet 2015;386(10005):1747–53.

Nath S, DiMarco JP, Haines DE. Basic aspects of radiofrequency catheter ablation. J Cardiovasc Electrophysiol 1994;5(10):863–76.

Lam P, Saba S. Approach to the evaluation and management of wide complex tachycardias. Indian Pacing Electrophysiol J 2002;2(4):120–6.

Wildenthal K, Leshin SJ, Atkins JM, Skelton CL. The diving reflex used to treat paroxysmal atrial tachycardia. Lancet 1975;1(7897):12–4.

Çorbacıoğlu ŞK, Akıncı E, Çevik Y, Aytar H, Öncül MV, Akkan S, et al. Comparing the success rates of standard and modified Valsalva maneuvers to terminate PSVT: A randomized controlled trial. Am J Emerg Med 2017;35(11):1662–5.

Richardson DA, Bexton R, Shaw FE, Steen N, Bond J, Kenny RA. Complications of carotid sinus massage--a prospective series of older patients. Age Ageing 2000;29(5):413–7.

Innes JA. Review article: adenosine use in the emergency department. Emerg Med Australas 2008;20(3):209–15.

Mohammad AM, Saeed MS, Migliore F. Effectiveness of the modified Valsalva maneuver in the emergency management of supraventricular tachycardia. Med J Babylon 2019;16(2):104–7.

Stambler BS, Dorian P, Sager PT, Wight D, Douville P, Potvin D, et al. Etripamil nasal spray for rapid conversion of supraventricular tachycardia to sinus rhythm. J Am Coll Cardiol 2018;72(5):489–97.

Taylor DM, Wong LF. Incorrect instruction in the use of the Valsalva maneuver for paroxysmal supraventricular tachycardia is common. Emerg Med Australas 2004;16:284–7.

Walker S, Cutting P. Impact of modified Valsalva maneuver in the termination of paroxysmal SVT. Emerg Med J 2010;27(4):287–91.

Gagg J. Southwest SVT survey: current Valsalva maneuver techniques in adults with supraventricular tachycardia. EMTA Conference, 2011; p.13–5.

Smith GD, Fry MM, Taylor D, Morgans A, Cantwell K. Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia. Cochrane Database Syst Rev 2015;2:CD009502.

Mehta D, Wafa S, Ward DE, Camm AJ. Relative efficacy of various physical maneuvers in the termination of junctional tachycardia. Lancet 1988;28(8596):1181–5.

Logga R. The Valsalva maneuver—cardiovascular effects and performance technique: a critical review. Respir Physiol Neurobiol 2005;147(1):39–49.

Appelbaum A, Gagg J, Reuben AR. Modified Valsalva maneuver to treat recurrent supraventricular tachycardia: description of the technique and its successful use in a patient with a previous near-fatal complication of DC cardioversion. BMJ Case Rep 2014;2014:bcr2013202699.

Wong LF, Taylor DM, Bailey M. Vagal response varies with Valsalva maneuver technique: A repeated measures clinical trial in healthy subjects. Ann Emerg Med 2004;43(4):477–82.

Chance JF, Warner JG, Elsawy T. Augmented Valsalva maneuver for supraventricular tachycardia in the young. Ann Intern Med 1992;116(6):523.

Bhagat K. Non-pharmacological termination of supraventricular tachycardia. Cent Afr J Med 1999;45(9):246–7.



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