Bradycardia, Renal Failure, Atrioventricular-nodal Blocker, Shock, and Hyperkalemia Syndrome Diagnosis and Literature Review

Sattar, Yasar; Bareeqa, Syeda Beenish; Rauf, Hiba; Ullah, Waqas; Alraies, M. Chadi

doi:10.7759/cureus.6985

Cited by 18 publications

(24 citation statements)

References 7 publications

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“…Numerous cases have been published in the medical literature since the disease was codified in 2016 [ 3 ]. Still, it has not been recognized as a distinct entity, and little is known about its epidemiology [ 4 ].…”

Section: Discussionmentioning

confidence: 99%

“…For example, ECG findings may range from junctional bradycardia to classic hyperkalemic changes, i.e., tall T waves, absent P and QRS widening even if the potassium level is mildly elevated [ 1 - 4 ]. Furthermore, there is disproportionality between the severity of bradycardia and AV nodal blocking drugs in the blood that is within the normal therapeutic range [ 3 , 4 ]. The serum potassium level in our patient was 8.3 mEq/L; her ECG findings display junctional bradycardia rhythm with poor P progression.…”

Section: Discussionmentioning

confidence: 99%

“…The clinical manifestation varies from asymptomatic bradycardia to shock [ 1 , 2 ]. The therapeutic approach consists of basic supportive measures for hyperkalemia, bradycardia, and resuscitation with fluid therapy [ 3 ]. Herein, we present a case of BRASH syndrome with severe resistant hyperkalemia and bradycardia in a patient taking metoprolol tartrate.…”

Section: Introductionmentioning

confidence: 99%

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

Khan¹,

Lahmar²,

Ehtesham³

et al. 2022

Cureus

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

Khan¹,

Lahmar²,

Ehtesham³

et al. 2022

Cureus

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“…The synergism between AV nodal blocking medications and hyperkalemia leads to bradycardia, which gradually leads to hypotension (by decreasing the cardiac output) [ 11 , 12 ]. This leads to organ hypoperfusion, mainly of kidneys, further worsening the renal function and thus leading to the vicious cycle of renal failure - hyperkalemia - bradycardia - shock - renal failure [ 1 , 13 ]. This process continues to cause multiorgan dysfunction until intervention from outside to correct the kidney function.…”

Section: Discussionmentioning

confidence: 99%

BRASH Syndrome Leading to Cardiac Arrest and Diffuse Anoxic Brain Injury: An Underdiagnosed Entity

Ghumman

Kumar

2021

Cureus

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BRASH (bradycardia, renal failure, atrioventricular [AV] nodal blocking medications, shock, hyperkalemia) syndrome describes the phenomenon of profound bradycardia from a combination of hyperkalemia and use of AV nodal blocking medication with underlying renal injury. We present a case of BRASH syndrome in a patient on chronic beta-blocker therapy for his coronary artery disease who presented with life-threatening hyperkalemia and acute renal failure. Due to failure in early recognition and superimposed effect with further beta-blocker dosing, the patient developed profound bradycardia and later went into pulseless electrical activity cardiac arrest requiring cardiopulmonary resuscitation. Metabolic derangements and bradycardia later resolved with medical management, but unfortunately, the patient developed diffuse anoxic brain injury after the cardiac arrest and was declared brain dead.

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“…According to the Advanced Cardiac Life Support (ACLS) algorithm, if there are signs of shock due to bradycardia, atropine should be administered, and if atropine does not work, percutaneous pacing should be considered [2]. However, bradycardia due to BRASH syndrome does not respond to this algorithm [3].…”

mentioning

confidence: 99%

BRASH syndrome associated with angiotensin receptor blocker and SGLT2 inhibitor

Nagamine

2021

Can J Emerg Med

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Bradycardia, Renal Failure, Atrioventricular-nodal Blocker, Shock, and Hyperkalemia Syndrome Diagnosis and Literature Review

Cited by 18 publications

References 7 publications

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

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

BRASH Syndrome Leading to Cardiac Arrest and Diffuse Anoxic Brain Injury: An Underdiagnosed Entity

BRASH syndrome associated with angiotensin receptor blocker and SGLT2 inhibitor

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