Unexpected Presentations of Bradycardia, Renal Failure, Atrioventricular Nodal Blockade, Shock, and Hyperkalemia (BRASH) Syndrome: A Report of Two Cases

Abstract

Bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia syndrome is an underrecognized phenomenon in which renal injury leads to hyperkalemia and inadequate clearance of atrioventricular nodal-blocking agents. The compounding effect of both insults can lead to a bradyarrhythmia that, in severe cases, can rapidly progress to cardiogenic shock. The degree of resulting pathology is usually out of proportion to either insulting agent given that there is a synergistic effect. Treatment strategies for this condition are not entirely clear, but it appears as if these patients often do not warrant aggressive interventions and can be managed medically. We report two cases with early recognition and simple medical management with resulting favorable outcomes.

Keywords: bradycardia; brash syndrome; cardiogenic shock; hyperkalemia; renal failure.

Figure 1. Initial electrocardiogram revealing junctional bradycardia at a rate of 33 beats per minute.

Figure 2. Repeat electrocardiogram several hours after shifting of hyperkalemia, revealing normal sinus rhythm at a rate of 64 beats per minute.

Figure 3. Initial electrocardiogram revealing junctional bradycardia at a rate of 49 beats per minute.