https://www.uptodate.com/contents/vagal-maneuvers/print 13/21 7/6/23, 10:44 AM Vagal maneuvers - UpToDate Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2016; 133:e506. 8. Schweitzer P, Teichholz LE. Carotid sinus massage. Its diagnostic and therapeutic value in arrhythmias. Am J Med 1985; 78:645. 9. Hess DS, Hanlon T, Scheinman M, et al. Termination of ventricular tachycardia by carotid sinus massage. Circulation 1982; 65:627. 10. Wei JY, Greene HL, Weisfeldt ML. Cough-facilitated conversion of ventricular tachycardia. Am J Cardiol 1980; 45:174. 11. Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet 2015; 386:1747. 12. Ceylan E, Ozpolat C, Onur O, et al. Initial and Sustained Response Effects of 3 Vagal Maneuvers in Supraventricular Tachycardia: A Randomized, Clinical Trial. J Emerg Med 2019; 57:299. 13. DERBES VJ, KERR A Jr. Valsalva's maneuver and Weber's experiment. N Engl J Med 1955; 253:822. 14. IRVIN CW Jr. Valsalva maneuver as a diagnostic aid. J Am Med Assoc 1959; 170:787. 15. Smith G, Morgans A, Boyle M. Use of the Valsalva manoeuvre in the prehospital setting: a review of the literature. Emerg Med J 2009; 26:8. 16. Zema MJ. Diagnosing Heart Failure by the Valsalva Maneuver: Isn't it Finally Time? JACC Heart Fail 2018; 6:969. 17. Zema MJ, Restivo B, Sos T, et al. Left ventricular dysfunction bedside Valsalva manoeuvre. Br Heart J 1980; 44:560. 18. Zema MJ, Masters AP, Margouleff D. Dyspnea: the heart or the lungs? Differentiation at bedside by use of the simple Valsalva maneuver. Chest 1984; 85:59. 19. LOWN B, LEVINE SA. The carotid sinus. Clinical value of its stimulation. Circulation 1961; 23:766. 20. Richardson DA, Bexton R, Shaw FE, et al. Complications of carotid sinus massage a prospective series of older patients. Age Ageing 2000; 29:413. 21. Brignole M, Moya A, de Lange FJ, et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39:1883. 22. Pasquier M, Clair M, Pruvot E, et al. Carotid Sinus Massage. N Engl J Med 2017; 377:e21. 23. Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of https://www.uptodate.com/contents/vagal-maneuvers/print 14/21 7/6/23, 10:44 AM Vagal maneuvers - UpToDate Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol 2017. 24. Davies AJ, Kenny RA. Frequency of neurologic complications following carotid sinus massage. Am J Cardiol 1998; 81:1256. 25. Reyners AK, Tio RA, Vlutters FG, et al. Re-evaluation of the cold face test in humans. Eur J Appl Physiol 2000; 82:487. 26. Duprez D, De Buyzere M, Trouerbach J, et al. Continuous monitoring of haemodynamic parameters in humans during the early phase of simulated diving with and without breathholding. Eur J Appl Physiol 2000; 81:411. 27. Gooden BA. The diving response in clinical medicine. Aviat Space Environ Med 1982; 53:273. 28. Van Brocklin MD, Hirons RR, Yolton RL. The oculocardiac reflex: a review. J Am Optom Assoc 1982; 53:407. 29. Brignole M, Menozzi C, Gianfranchi L, et al. Carotid sinus massage, eyeball compression, and head-up tilt test in patients with syncope of uncertain origin and in healthy control subjects. Am Heart J 1991; 122:1644. 30. Allison CE, De Lange JJ, Koole FD, et al. A comparison of the incidence of the oculocardiac and oculorespiratory reflexes during sevoflurane or halothane anesthesia for strabismus surgery in children. Anesth Analg 2000; 90:306. 31. Puggioni E, Guiducci V, Brignole M, et al. Results and complications of the carotid sinus massage performed according to the "method of symptoms". Am J Cardiol 2002; 89:599. Topic 1034 Version 31.0 https://www.uptodate.com/contents/vagal-maneuvers/print 15/21 7/6/23, 10:44 AM Vagal maneuvers - UpToDate GRAPHICS Conditions in which vagal maneuvers may be useful diagnostically or therapeutically Tachyarrhythmias Narrow, regular supraventricular tachycardias Sinus tachycardia Conduction abnormalities 2:1 atrioventricular block Bundle branch blocks Preexcitation Other cardiovascular uses Carotid sinus hypersensitivity Pulmonary edema Courtesy of Peter J Zimetbaum, MD and Daniel Frisch, MD. Graphic 67134 Version 4.0 https://www.uptodate.com/contents/vagal-maneuvers/print 16/21 7/6/23, 10:44 AM Vagal maneuvers - UpToDate Valsalva maneuver The Valsalva maneuver is performed with the patient supine or in a semirecumbent position and instructed to exhale forcefully against a closed glottis after a normal inspiratory effort (ie, at tidal volume). Signs of adequacy include neck vein distension, increased tone in the abdominal wall muscles, and a flushed face. The patient should maintain the strain for 10 to 15 seconds and then release it and resume normal breathing. A modified Valsalva maneuver involves the standard strain (40 mmHg pressure for 15 seconds in the semirecumbent position at 45 degrees) immediately followed by lowering the trunk to a supine position with passive leg raise at a 45 degree angle for 15 seconds. The modified Valsalva maneuver has been shown to be more successful in restoring sinus rhythm for patients with supraventricular tachycardia. Modi ed from: Hunter C. Slow down, you re going too fast: SVT and The Modi ed Valsalva Maneuver. CPR Seattle 2019. Graphic 130499 Version 1.0 https://www.uptodate.com/contents/vagal-maneuvers/print 17/21 7/6/23, 10:44 AM Vagal maneuvers - UpToDate Normal blood pressure responses to the Valsalva maneuver Normal Valsalva response: Normal changes in systolic blood pressure during 10 seconds of straining (shaded). Phase 1 - systolic blood pressure rises with initiation of the maneuver. Phase 2 - systolic blood pressure returns to baseline after several seconds. Phase 3 - systolic blood pressure drops below normal after strain is released. Phase 4 - systolic blood pressure rises transiently before returning to baseline. Graphic 78776 Version 4.0 https://www.uptodate.com/contents/vagal-maneuvers/print 18/21 7/6/23, 10:44 AM Vagal maneuvers - UpToDate Anatomy of the carotid sinus The carotid sinus is located at the base of the internal carotid artery just superior to its bifurcation from the external carotid artery. Graphic 139405 Version 1.0 https://www.uptodate.com/contents/vagal-maneuvers/print 19/21 7/6/23, 10:44 AM Vagal maneuvers - UpToDate Potential complications of selected vagal maneuvers Vagal maneuver Potential complication Valsalva maneuver Rupture of the round window of the ear Carotid sinus massage Decreased cerebral perfusion, cerebral embolism Ice-water immersion Aspiration, drowning, pregnancy complications Eyeball compression Ocular injury Courtesy of Peter J Zimetbaum, MD and Daniel Frisch, MD. Graphic 79543 Version 5.0 https://www.uptodate.com/contents/vagal-maneuvers/print 20/21 7/6/23, 10:44 AM Vagal maneuvers - UpToDate Contributor Disclosures Daniel R Frisch, MD Other Financial Interest: Abbott [Arrhythmias speaking engagement]; St Jude Medical [Arrhythmias speaking engagement]. All of the relevant financial relationships listed have been mitigated. Peter J Zimetbaum, MD Consultant/Advisory Boards: Abbott Medical [Lead extraction]. All of the relevant financial relationships listed have been mitigated. Brian Olshansky, MD Other Financial Interest: AstraZeneca [Member of the DSMB for the DIALYZE trial]; Medtelligence [Cardiovascular disease]. All of the relevant financial relationships listed have been mitigated. Susan B Yeon, MD, JD, FACC No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/vagal-maneuvers/print 21/21