Tachycardia management turned upside down

Doing a hand stand or being turned upside down is an effective way of treating childhood superventricular tachycardia compared to the standard Valsalva manoeuvre, a small study suggests.

The Italian randomised controlled pilot study compared the two vagal manoeuvres for acute at-home treatment of paroxysmal superventricular tachycardia (SVT) in 24 children aged one to 18.

The children retained the upside-down position for 30 seconds – smaller children were manually flipped while older ones performed a handstand – or blew into a 10mL syringe to move the plunger for 15 seconds (from a semi-recumbent position), after the onset of SVT in a home setting.

The researchers reported that 67% of patients who used the upside-down position achieved cardioversion at the first attempt, compared to 33% for VM.

Where the intervention failed, the child used the second vagal manoeuvre, and in this case the upside-down position achieved cardioversion in 50% of patients compared to 0% who used VM.

According to the study design the groups assigned to intervention were swapped with results showing 67% v 25% and 71% v 42% in favour of the upside-down technique.

Writing in the International Journal of Cardiology the researchers speculate the upside down position is more effective because it generates massive and sudden increase in venous return, and atrial stretching that can interact with the conduction pathways involved in the re-entrant circuit.

They conclude while the study is small, it suggests the upside-down position is safe and more effective than standard VM.

“It is crucial that this manoeuvre is known not only by parents but by all doctors involved in the management of children with episodes of tachycardia”.

Professor Jon Skinner, a paediatric cardiologist and electrophysiologist at the Starship Children’s Hospital in Auckland, said the study confirms what cardiologists have known anecdotally for years.

“We’ve known handstands in older children are reasonably accepted as a means for getting kids out of SVT and anecdotally a lot of us have been telling our patients to hang over a sofa and things like that,” said Professor Skinner, chair of CSANZ’s genetic council.

“So, it’s nice to have a comparison against a standard technique.

Paediatric cardiologists should consider adding the upside down position to their list of recommended vagal manouevres for managing SVT, he said.

“A single study shouldn’t change international guidelines but you could say ‘at least it’s not inferior and if your child would feel more comfortable doing this first, then why not’?”

 “One of the things that can happen when you’re in an SVT is kids can lose confidence that their treatment is going to work so it’s really nice to have something which has a greater (chance) of working first up, rather than trying two or three things every time.”

The intervention however is not suitable for patients experiencing dizziness or older people with co-morbidities such as neck problems, he said.

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