Pursuit of Optimal Vagal Maneuvers in Stable Supraventricular Tachycardia: A Network Meta-Analysis

Vagal maneuvers are first-line therapy for hemodynamically stable supraventricular tachycardia (SVT), yet the relative efficacy of the standard Valsalva Maneuver (SVM), modified Valsalva maneuver (MVM), carotid-sinus massage (CSM), and head-down deep breathing (HDDB) remains uncertain. We undertook a network meta-analysis (NMA) to define the optimal technique and explore age- and sex-related effect modification.

We searched nine databases from inception to January 2025 for randomized controlled trials involving adults (≥ 18 years of age) with stable SVT treated with at least two of the four maneuvers. Primary outcomes were conversion to sinus rhythm after a single attempt after multiple attempts, and by the end of the trial. Secondary outcomes were the need for rescue intravenous (IV) antiarrhythmic drugs and maneuver-related adverse events (AEs). Bayesian random-effects NMA generated risk ratios (RR) with 95% credible intervals (CrIs); surface under the cumulative ranking curve (SUCRA) quantified hierarchy. We performed consistency, publication bias, and sensitivity analyses, and network meta-regression for mean age and female proportion.

Nineteen trials (n = 2,545) formed a connected network. The MVM was more than doubly effective for single-attempt conversion relative to the SVM (RR 2.71, 95% CrI, 2.26-3.31) and outperformed CSM (RR 6.57, 3.33-14.94) and HDDB (RR 1.30, 0.35-4.66); SUCRA = 88.7%. At the end of the trial, the MVM retained superiority over the SVM (RR 1.25, 1.03-1.56) and ranked the highest success rate (SUCRA = 81.3%). The MVM also reduced IV drug use vs the SVM (RR 0.64, 0.55-0.73) and CSM (RR 0.59, 0.37-0.90). No maneuver differed in multiple-attempt success or AEs. The HDDB technique was ranked highest in safety (SUCRA = 82.4%) but was supported only by a single, small study. Meta-regression showed no age or sex interaction. Inconsistency was minimal; the Egger test suggested small-study effects only for the IV-drug endpoint (P = .03).

The MVM provides the greatest likelihood of rapid sinus rhythm restoration and the least need for rescue pharmacotherapy without increasing AEs, supporting its adoption as the default vagal strategy for SVT. Larger, standardized trials are warranted to confirm safety differentials and long-term outcomes.