Bradycardia, Renal Failure, Atrioventricular (AV) Nodal Blockers, Shock, and Hyperkalemia (BRASH) Syndrome: A Confounder in the Clinical Practice

BRASH, an acronym for Bradycardia, Renal failure, AV nodal blockers, Shock, and Hyperkalemia, syndrome is a clinical synergic phenomenon that can result in cardiovascular collapse. We present the case of an 83-year-old woman with dilated cardiomyopathy, heart failure, and chronic kidney disease who was admitted to the emergency room due to syncope and a worsening general condition. The patient was on several medications, including carvedilol, a beta-blocker. On physical examination, she was found to be hypotensive and bradycardic, with no other significant findings. Laboratory results revealed urea of 161 mg/dL, creatinine of 2.7 mg/dL, and potassium of 5.2 mEq/L. The electrocardiogram showed bradycardia with a regular junctional rhythm without signs of ischemia or other alterations. Given the patient's bradycardia, hyperkalemia, and renal dysfunction, atropine was administered, but no significant clinical response was observed. The patient's condition worsened, with progressive bradycardia, oliguria, and neurological dysfunction. Based on the combination of these findings, a diagnosis of BRASH syndrome was made. Treatment was initiated with isoproterenol to stimulate heart rate, along with fluid therapy, calcium gluconate, and insulin to address hyperkalemia. The bradycardia gradually improved, allowing the discontinuation of isoproterenol after 24 hours. The BRASH syndrome is a potentially life-threatening condition that can go unrecognized without early identification. This case underscores the importance of swift diagnosis and timely intervention in managing BRASH syndrome. The combination of factors, including hyperkalemia, bradycardia, and renal failure in patients on atrioventricular nodal blockers, should always raise suspicion for this condition. Rapid and targeted therapy is essential to prevent adverse outcomes and ensure the patient's recovery.