Clinical characteristics of BRASH syndrome: Systematic scoping review

Shah, Parthav; Gozun, Maan; Keitoku, Koichi; Kimura, Nobuhiko; Yeo, Jun Sang; Czech, Torrey; Nishimura, Yoshito

doi:10.1016/j.ejim.2022.06.002

Cited by 15 publications

(25 citation statements)

References 30 publications

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“…The phenomenon is now known as the "BRASH phenomenon" or "BRASH syndrome" [1]. This novel, under-recognized clinical entity is epitomized by a clinical quintet of bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia (BRASH) [1][2][3][4][5][6][7]. Although the incidence of BRASH syndrome is unknown, it is feasible for this uncommon manifestation to present in the emergency department due to the widespread use of atrioventricular (AV) nodal blockers for hypertension, chronic renal disease, and ischemic heart disease [2].…”

Section: Introductionmentioning

confidence: 99%

“…The prevalence of BRASH syndrome is greater than what has been documented in the medical literature. When a patient with modest hyperkalemia develops substantial bradycardia, emergency doctors should have a high degree of suspicion for BRASH syndrome [1,3,4]. reports and series, and 15 conference abstracts revealed that patients' symptoms could not be relieved by atropine or glucagon; 59.5% needed inotropes or chronotropes instead, and 7.1% of people died due to BRASH syndrome [3].…”

Section: Introductionmentioning

confidence: 99%

“…Although the incidence of BRASH syndrome is unknown, it is feasible for this uncommon manifestation to present in the emergency department due to the widespread use of atrioventricular (AV) nodal blockers for hypertension, chronic renal disease, and ischemic heart disease [ 2 ]. So far, there have been limited studies that have defined the demographics, definitive clinical features, severity of the illness, or prognosis of BRASH syndrome [ 3 ]. However, this is more frequent in older adults with heart disease and low renal reserve owing to the use of antihypertensive medications and having borderline renal function [ 4 ].…”

Section: Introductionmentioning

confidence: 99%

“…The existing literature available on BRASH syndrome has a great deal of variation in terms of clinical presentations, contributing variables, and therapy [ 3 , 5 , 6 ]. Although the incidence of each symptom is not well reported, preliminary symptoms may include generalized weakness or nonspecific symptoms like syncope and can manifest in a variety of ways, from coincidental bradycardia to multiorgan failure [ 5 ].…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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A Case Report on BRASH (Bradycardia, Renal Failure, Atrioventricular Blockade, Shock, and Hyperkalaemia) Syndrome: A Challenging Diagnosis

Roy¹,

Rafa²,

Agrawal³

et al. 2022

Cureus

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A relatively new yet critical phenomenon of bradycardia, renal failure, atrioventricular (AV) blockade, shock, and hyperkalemia (BRASH) syndrome is hypothesized to happen in patients who take atrioventricular nodal blocking (AVNB) agents and have underlying renal insufficiency. In our case, a 67-year-old female with an extensive medical history presented to the emergency room with chief complaints of decreased appetite, nausea, vomiting, fatigue, and left-sided atypical chest pain for the past two weeks. The patient was taking losartan potassium 50 mg daily in addition to carvedilol 6.25 mg twice daily for her hypertension (HTN) and heart failure with reduced ejection fraction (HFrEF) with the addition of bumetanide 0.5 mg, which was added three weeks prior. On presentation, the patient had sinus bradycardia and hypotension along with the laboratory finding of acute kidney injury (AKI) in the setting of chronic kidney disease (CKD) and hyperkalemia. Cardiology and nephrology were consulted emergently; her clinical scenario raised suspicion of the BRASH syndrome. The patient was admitted to the intensive care unit (ICU), and all antihypertensive medications, including beta-blockers, were stopped. Intravenous (IV) fluid resuscitation and medical management of hyperkalemia were initiated, along with BiPAP for respiratory distress. She responded significantly, and her vitals remained stable. She was successfully discharged home with a cardiology and nephrology follow-up. We highlight the case to emphasize the consideration of BRASH in a patient on multiple cardiac medications who presented with deranged electrolytes and organ failure, and decompensated heart failure (HF) should not be fixed on as the principal diagnosis.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

A Case Report on BRASH (Bradycardia, Renal Failure, Atrioventricular Blockade, Shock, and Hyperkalaemia) Syndrome: A Challenging Diagnosis

Roy¹,

Rafa²,

Agrawal³

et al. 2022

Cureus

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A Case of BRASH Syndrome Presenting With Refractory Hyperkalemia Requiring Intermittent Hemodialysis

Khadka,

Poudel,

Khanal

et al. 2024

Clinical Case Reports

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BRASH syndrome characterized by bradycardia, renal dysfunction, atrioventricular nodal blockade (AVNB), shock, and hyperkalemia presents diagnostic and management challenges due to its complex pathophysiology and varied clinical presentations. We describe a 90‐year‐old woman with a history of multiple comorbidities who was on beta blockers bisoprolol for heart failure, presented with shock, refractory hyperkalemia along with bradycardia that required intermittent hemodialysis. Initial management involved aggressive hyperkalemia medical therapy and fluid resuscitation, with subsequent consideration of renal replacement therapy hemodialysis following collaboration with a multidisciplinary team, including cardiology and nephrology specialists. Despite aggressive medical management for hyperkalemia, some cases of BRASH syndrome may remain challenging to treat, requiring intermittent hemodialysis highlighting the need for further research and understanding of this complex clinical entity to improve treatment outcomes.

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Rare presentation of BRASH syndrome with hypoglycemia and altered mental status

et al. 2023

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Background BRASH syndrome (bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia) is a rare clinical condition with potentially severe outcomes. Patients with BRASH syndrome can present with diverse signs and symptoms and are usually in critical condition, but if recognized early, the syndrome is treatable and may have a favorable prognosis. Case presentation This case study presents a 74-year-old patient with a history of multiple chronic conditions who was brought to the emergency department with a suspected cerebrovascular accident, altered mental status, and bradycardia. A head computed tomography scan was unremarkable but laboratory results showed hyperkalemia, acidosis, and renal failure with concomitant progressive hypoglycemia. The patient was diagnosed with a BRASH syndrome characterized by a vicious cycle of atrioventricular nodal blockade induced by the potentiated effect of beta-blockers or calcium channel blockers, in combination with progressive hypoglycemia due to the suspected accumulation of anti-diabetic medications, which influenced the presentation and initial triage in the emergency department. She was admitted to the intensive care unit for further management, where she continued to improve and was ultimately discharged in a relatively stable condition. Conclusion This case study highlights the importance of considering rare and atypical presentations of medical conditions, particularly in elderly patients who may have multiple comorbidities. Early recognition and prompt management of such cases are crucial for improving patient outcomes.

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Clinical characteristics of BRASH syndrome: Systematic scoping review

Cited by 15 publications

References 30 publications

A Case Report on BRASH (Bradycardia, Renal Failure, Atrioventricular Blockade, Shock, and Hyperkalaemia) Syndrome: A Challenging Diagnosis

A Case Report on BRASH (Bradycardia, Renal Failure, Atrioventricular Blockade, Shock, and Hyperkalaemia) Syndrome: A Challenging Diagnosis

A Case of BRASH Syndrome Presenting With Refractory Hyperkalemia Requiring Intermittent Hemodialysis

Rare presentation of BRASH syndrome with hypoglycemia and altered mental status

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