Bradycardia, Renal Failure, Atrioventricular-Nodal Blockade, Shock, and Hyperkalemia Syndrome: A Case Report

Abstract

Bradycardia, renal failure, atrioventricular (AV) blockade, shock, and hyperkalemia (BRASH) syndrome is an uncommon and relatively new entity that results from synergy between AV nodal blockade and renal failure leading to a vicious cycle of hypotension, profound bradycardia, and hyperkalemia. Classically, this syndrome is seen in a patient taking AV nodal blocking agents and underlying renal insufficiency. We are presenting a case of a 76-year-old female with a medical history of essential hypertension and non-insulin-dependent type 2 diabetes mellitus presented to the emergency room with a chief complaint of dizziness and generalized weakness. The patient was taking metoprolol tartrate 200 mg twice a day, amlodipine 10 mg once daily, clonidine 0.1 mg twice daily, enalapril 20 mg twice daily, and Metformin 750 mg twice daily. On presentation, the patient had symptomatic bradycardia resistant to atropine with heart rate in 30s and hypotension resistant to volume expansion. The laboratory results showed that the patient also had acute kidney injury and severe resistant hyperkalemia. The whole presentation raised the suspicion of BRASH syndrome. The patient was started on peripheral dopamine infusion for bradycardia and symptomatic hypotension. Nephrology was consulted, and the patient was started on urgent dialysis for resistant hyperkalemia. The patient was admitted to the cardiovascular intensive care unit, and all antihypertensive medication, including beta-blockers, were stopped. The patient clinically improved on the next day, the dopamine infusion was stopped, and the patient remained vitally stable. The patient was eventually discharged home with cardiology and nephrology follow-up. The purpose of this case report is to help with the early diagnosis of this under-recognized and new clinical condition and to discuss the pathophysiology and management.

BRASH Syndrome Presenting With Idioventricular Escape Rhythm in a Patient With Trifascicular Block

“…As in our case, atropine was not sufficient to manage the bradycardia, and even the applied pacemaker was not utilized. Similar to other studies [1,3,7,8], transcutaneous pacemaker implantation is unnecessary in the management of the transient bradycardia that occurs in BRASH syndrome. Probably, the treatment of hyperkalemia appears to be the most effective factor.…”

“…Most patients present anywhere within this spectrum with symptoms related to the precipitants. The symptoms of BRASH syndrome can mimic the presentation of cardiac disorders such as renal diseases, associated with cardiac conduction disorders [5][6][7][8][9]. Nevertheless, regardless of any presenting pattern, there is always profound bradycardia [2,3].…”

“…In making the diagnosis, besides the clinical history of the precipitants, BRASH syndrome is often clinically distinguished from other similar conditions by the presence of bradycardia amidst mild hyperkalemia, the absence of overdosing of AV nodal blockers, and an ECG with disproportionate bradycardia [ 1 - 3 , 7 ]. Bradycardia is typically seen in isolated hyperkalemia at serum potassium levels equal to or above 7.0 mEq/L, unlike in BRASH where bradycardia is seen in mild cases as low as 5.1 mEq/L [ 2 , 3 ].…”

BRASH Syndrome: A Case Report and Literature Review

“…Furthermore, we explored the need to escalate treatment to include three specific aggressive interventions for BRASH syndrome, including temporary transcutaneous or transvenous pacing due to persistent bradyarrhythmias, emergent dialysis for electrolyte imbalances or fluid overload status, and adrenergic medications to maintain systemic perfusion. After an extensive literature search of all case reports from 2020 to the present, we identified 17 cases of documented BRASH syndrome that fulfilled all five components of the diagnosis, including known exposure to an AV-nodal blocking agent [8][9][10][11][12][13][14][15][16][17][18][19][20][21].…”

Síndrome de BRASH con presentación electrocardiográfica no común. Reporte de caso

“…Junto con el bloqueo aurículo-ventricular (BAV) se han descrito, en el trazo electrocardiográfico, ausencia de ondas p, ritmo de la unión aurículo-ventricular con ondas p ausentes, bradicardia y pobre progresión de la onda R (Khan, A., 2022). Hasta donde sabemos, no se han descrito casos de síndrome de BRASH con BAV asociado a bloqueo de rama izquierda.…”