Two Cases of BRASH Syndrome: A Diagnostic Challenge

Abstract

Bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia (BRASH) syndrome is a relatively new clinical entity. It is often underrecognized, underdiagnosed, and confused with other causes of bradycardia. Treatment of BRASH syndrome differs from the standard bradycardia algorithm in advanced cardiac life support (ACLS), and the cornerstone management remains treating the hyperkalemia, improving renal function by treating the underlying cause, withholding AV nodal blocking agents, and considering dialysis in refractory cases, as any single factor could precipitate the vicious cycle. Here we describe two cases of BRASH syndrome with different clinical presentations that were treated with conservative management: one case in a 77-year-old Japanese woman and the other in an 86-year-old man.

Learning points: BRASH syndrome is an underrecognized clinical entity that healthcare providers need to be aware of. A medication review, particularly of cardiac medications, including AV nodal blocking agents, is critical for diagnosing BRASH syndrome.The management principles of BRASH syndrome are conservative management, addressing the precipitating event or medications and correcting electrolyte derangements.The prognosis of BRASH syndrome is excellent with timely recognition and management.

Keywords: BRASH syndrome; atrioventricular nodal blocker; bradycardia; hyperkalemia; renal failure; shock.

Figure 1

Electrocardiogram on admission, Case 1 Electrocardiogram on admission showing idiopathic ventricular rhythm with a heart rate of 30 bpm

Figure 2

Electrocardiogram on admission, Case 2 Electrocardiogram on admission showing junctional rhythm with a heart rate of 30–40 bpm.