Case Report: BRASH Syndrome

BRASH (bradycardia, renal failure, atrioventricular blockage, shock, and hyperkalemia) syndrome is a relatively new phenomenon. BRASH is thought to occur in patients who are treated with atrioventricular nodal blocking (AVNB) agents and have underlying renal insufficiency. Pooja Roy, MD, and colleagues presented a case report of a patient with BRASH [Cureus. doi:10.7759/cureus.32704].

The patient was a 67-year-old female with an extensive medical history. The patient presented to the emergency department with primary complaints of decreased appetite, nausea, vomiting, fatigue, and left-sided atypical chest pain for the past 2 weeks. She was taking losartan potassium 50 mg daily as well as carvedilol 6.25 mg twice daily for hypertension and heart failure with reduced ejection fraction, with the addition of bumetanide 0.5 mg (added 3 weeks prior)

On presentation, the patient had sinus bradycardia and hypotension, as well as the laboratory finding of acute kidney injury in the setting of chronic kidney disease and hyperkalemia. Cardiology and nephrology were consulted emergently; her clinical condition raised suspicion of BRASH syndrome.

The patient was admitted to the intensive care unit and all antihypertensive medications, including beta-blockers, were stopped. Intravenous 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.

The authors said, “We highlight the case to emphasize the consideration of BRASH in a patient on multiple cardiac mediations who presented with deranged electrolytes and organ failure, and decompensated heart failure should be fixed on as the principal diagnosis.”