Use and effectiveness of the Valsalva maneuver for supraventricular tachycardia in prehospital emergency care: a retrospective cohort study

Abstract

Background

Vagal maneuvers are recommended as first-line therapy for hemodynamically stable supraventricular tachycardia (SVT). However, real-world data on their use in prehospital emergency medical services (EMS) remain limited.

Aim

To evaluate the utilization and effectiveness of the Valsalva maneuver in the prehospital management of tachyarrhythmia, with particular focus on patients with confirmed SVT.

Methods

A retrospective cohort study was conducted using EMS documentation from a regional EMS system in Poland between 2023 and 2024. Among 93,847 EMS interventions, 235 cases coded as unspecified tachycardia (ICD-10 R00.0) were identified. Data included patient demographics, ECG findings, syncope, performance and outcome of the Valsalva maneuver, and hospital transport decisions. Subgroup analysis focused on patients with ECG-confirmed SVT.

Results

SVT was documented in 71 patients (30.2%). The Valsalva maneuver was performed in 13 patients (5.5% of the cohort) and in 18.3% of those with confirmed SVT. Sustained conversion to sinus rhythm occurred in 5 of 13 patients (38.5%; 95% CI 13.9–68.4%), with transient improvement in one additional case. All attempts were performed in patients with narrow-complex tachycardia consistent with SVT. Hospital transport occurred in most patients regardless of maneuver performance or outcome.

Conclusions

In this EMS cohort, the Valsalva maneuver was infrequently used despite guideline recommendations. When performed, rhythm conversion occurred in a minority of cases and did not substantially influence transport decisions. These findings highlight the gap between guideline recommendations and real-world prehospital practice.

Background

Supraventricular tachycardia (SVT) is a common arrhythmia encountered in emergency medical services (EMS). It is typically characterized by sudden onset of a rapid narrow-complex rhythm and may cause palpitations, dizziness, dyspnea, chest discomfort, or syncope [1–3]. Although many episodes are hemodynamically stable, rapid recognition and appropriate treatment remain important in emergency care.

Current international guidelines recommend vagal maneuvers as first-line treatment for hemodynamically stable patients with suspected SVT [2–5]. These techniques increase parasympathetic tone and slow atrioventricular nodal conduction, potentially interrupting the re-entry circuit responsible for many forms of SVT. Among them, the Valsalva maneuver is widely used because of its simplicity, safety profile, and minimal resource requirements.

Evidence from clinical trials and meta-analyses indicates that the modified Valsalva maneuver, which includes post-strain repositioning with passive leg elevation, may improve cardioversion rates compared with the standard technique [3–7]. However, real-world data on the use and effectiveness of vagal maneuvers in prehospital EMS practice remain limited.

The aim of this study was to evaluate the utilization and effectiveness of the Valsalva maneuver in the prehospital management of suspected tachyarrhythmia, with particular focus on cases of confirmed SVT.

Methods

Study design and setting

A retrospective cohort study was conducted using EMS documentation from the Regional Emergency Medical Services Station in Bydgoszcz, Poland. The study included EMS interventions performed between 2023 and 2024.

Study population

Among 93,847 EMS interventions during the study period, 235 cases coded as unspecified tachycardia (ICD-10 R00.0) were identified. ECG recordings were available for 206 cases. SVT was defined as regular narrow-complex tachycardia (QRS < 120 ms) documented on ECG during EMS assessment. ECG interpretation was performed by trained EMS personnel (paramedics, nurses, or physicians depending on team composition) as part of routine advanced life support practice in the Polish EMS system. A flow diagram illustrating case identification, exclusions, and analytic samples is presented in Fig. 1.

Fig. 1.

Flow diagram of case identification and study population selection. Among 93,847 EMS interventions, 235 cases coded as ICD-10 R00.0 were identified. ECG recordings were available for 206 cases, of which 71 were classified as supraventricular tachycardia (SVT). The Valsalva maneuver was performed in 13 patients

Data collection

Extracted variables included: patient age and sex, ECG rhythm, presence of syncope, performance of the Valsalva maneuver, outcome of the maneuver, decision regarding hospital transport.

Outcome definition

Effectiveness was categorized as:

• sustained conversion (sinus rhythm maintained ≥ 10 min),

• transient conversion (initial conversion with recurrence),

• no conversion.

Precise timestamps of ECG recordings and interventions were not consistently available.

Statistical analysis

Results were analyzed descriptively due to the small number of Valsalva attempts. Proportions are reported with exact 95% confidence intervals. Two-sided p-values < 0.05 were considered statistically significant.

Ethical approval

The study was approved by the Bioethics Committee of Nicolaus Copernicus University (No. 114/2025). All data were anonymized prior to analysis.

Results

The cohort included 235 EMS patients coded as ICD-10 R00.0 tachycardia, including 133 women (57%) and 102 men (43%). ECG recordings were available for 206 cases. SVT was documented in 71 patients (30.2%). Most patients (204/235, 86.8%) were transported to hospital.

The Valsalva maneuver was performed in 13 patients (5.5%). Among patients with confirmed SVT, the maneuver was attempted in 13 of 71 cases (18.3%). No attempts were recorded in patients without SVT.

Sustained conversion to sinus rhythm occurred in 5 of 13 patients (38.5%; 95% CI 13.9–68.4%). Transient improvement occurred in one additional patient. Outcomes by technique are shown in Table 1.

Table 1.

Effectiveness of the Valsalva maneuver (n = 13)

Type of Valsalva	Effective n (%)	Temporarily effective n (%)	Not effective n (%)
Classic Valsalva (n = 6)	3 (50.00%)	0 (0.00%)	3 (50.00%)
Modified Valsalva (n = 7)	2 (28.57%)	1 (14.29%)	4 (57.14%)

Percentages are calculated within each technique group

All Valsalva attempts were performed in patients with narrow-complex tachycardia consistent with SVT (Table 2).

Table 2.

Valsalva maneuver and supraventricular tachycardia (n = 206). Analysis restricted to cases with available ECG

SVT diagnosis	Valsalva YES n (%)	Valsalva NO n (%)
SVT present	13 (18.31%)	58 (81.69%)
SVT absent	0 (0%)	135 (100%)

Hospital transport occurred in 11 of 13 patients (84.6%) who underwent the Valsalva maneuver and in 194 of 222 patients (87.4%) who did not (Table 3).

Table 3.

Valsalva maneuver and patient transport to hospital (n = 235)

Transport to hospital	Valsalva YES (n = 13) n (%)	Valsalva NO (n = 222) n (%)
YES	11 (84.62%)	194 (87.39%)
NO	2 (15.38%)	28 (12.61%)

Discussion

This study provides real-world data on the use of the Valsalva maneuver in the prehospital management of tachyarrhythmias within an emergency medical services (EMS) system. Among 93,847 EMS interventions, tachycardia coded as ICD-10 R00.0 was identified in 235 cases (0.25%). Although relatively uncommon, tachyarrhythmias require careful evaluation because of the potential risk of hemodynamic instability.

Women constituted the majority of patients in our cohort, which is consistent with epidemiological observations indicating a higher prevalence of supraventricular tachyarrhythmias in females compared with males [1, 8]. The largest proportion of cases occurred in older adults, reflecting the well-established increase in arrhythmia incidence with advancing age and structural myocardial changes associated with cardiovascular disease [1, 8].

Syncope occurred infrequently and showed no significant association with arrhythmia type. This observation is consistent with previous reports indicating that loss of consciousness is uncommon in stable supraventricular tachycardia and more often accompanies severe hemodynamic disturbances or ventricular arrhythmias [1, 9, 10]. In most patients with SVT, symptoms are limited to palpitations, dizziness, dyspnea, or anxiety without loss of consciousness.

Although international guidelines recommend vagal maneuvers as first-line therapy for hemodynamically stable supraventricular tachycardia [2–5, 11], the Valsalva maneuver was used infrequently in the overall EMS cohort (5.5% of cases). When analysis was restricted to patients with confirmed SVT, the maneuver was attempted in 18.3% of cases. This pattern indicates that the maneuver was applied primarily in patients with suspected SVT.

Several factors may explain the relatively limited utilization rate. In the prehospital environment, diagnostic uncertainty regarding arrhythmia type, time pressure, and variability in provider experience may influence decision-making. In addition, operational protocols often prioritize rapid transport to hospital for further evaluation, which may limit the use of non-pharmacological interventions in the field [12, 13].

In the present study, conversion to sinus rhythm occurred in a minority of Valsalva attempts. Because of the small number of interventions, these findings should be interpreted descriptively. Evidence from randomized trials and meta-analyses suggests that optimized vagal maneuvers, particularly the modified Valsalva technique, may increase cardioversion success compared with the traditional maneuver [7, 14–17]. However, the present study was not designed to evaluate comparative effectiveness between techniques

Another important observation is that the performance or outcome of the Valsalva maneuver did not substantially influence hospital transport decisions. Most patients were transported regardless of rhythm conversion. This likely reflects the structure of prehospital care, where further diagnostic assessment and monitoring are usually required.

Recent research has also explored methods to improve performance of vagal maneuvers in prehospital settings. For example, the Valsalva Assist Device (VAD) has been proposed as a tool to standardize strain pressure and improve maneuver effectiveness [18]. However, recent evidence suggests that routine deployment of such devices in EMS systems does not significantly reduce hospital transport rates for suspected SVT [19].

Overall, these findings highlight a gap between guideline recommendations and their implementation in routine prehospital practice.

Study limitations

This study has several limitations. The retrospective design relies on routine EMS documentation, which may contain incomplete records. The analysis was conducted in a single regional EMS system, which may limit generalizability. The small number of Valsalva attempts prevented meaningful statistical comparisons. ECG interpretation was performed by EMS personnel without independent cardiology adjudication, which may introduce arrhythmia misclassification.

Conclusions

The Valsalva maneuver was rarely used in this EMS cohort despite guideline recommendations. When performed, rhythm conversion occurred in a minority of cases and did not substantially influence hospital transport decisions. Further prospective studies are needed to evaluate implementation of vagal maneuvers in prehospital care. Larger prospective multicenter studies are needed to evaluate implementation of vagal maneuvers in prehospital care.

Abbreviations

ECG

electrocardiography

EMS

emergency medical services

ICD

10-International Classification of Diseases, 10th revision

SVT

supraventricular tachycardia

VAD

Valsalva Assist Device

Author contributions

Conceptualization, P.Ż., T.B.; methodology, P.Ż, M.JZ.; software, T.B., E.K.; validation, P.Ż., E.K.; formal analysis, M.JZ.; investigation, P.Ż.,; resources, E.K., T.B.; data curation, P.Ż.; writing-original draft preparation, P.Ż., E.K., M.JZ. and A.B.; writing-review and editing, P.Ż., T.B., E.K., M.JZ. and A.B.; visualization, E.K., T.B.; supervision, P.Ż., A.B.; project administration, P.Ż. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Bioethics Committee of Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz issued on February 12, 2025 (approval No. 114/2025). The study was conducted in accordance with the Declaration of Helsinki and its later amendments. Due to the retrospective design of the study and the use of fully anonymized EMS documentation, the requirement to obtain informed consent from individual participants was waived by the Bioethics Committee in accordance with national regulations governing retrospective analyses of anonymized medical data.

Consent for publication

Not applicable. The manuscript does not contain any individual person’s data, images, or identifiable clinical information.

Competing interests

The authors declare no competing interests.