C16. BRASH (Bradycardia, Renal Failure, AV Nodal Blocker, Shock, and Hyperkalemia) Syndrome: Lost in Plain Sight

Bradycardia, Renal failure, AV-Nodal blockers, Shock, Hyperkalemia (BRASH) Syndrome new clinical entities due to a vicious cycle in which hyperkalemia from renal failure synergizes with AV-nodal blockers, consequently between the clinical condition of patients with the degree of hyperkalemia and bradycardia are inappropriate, Furthermore, the symptoms may be refractory to typical positive chronotropic interventions or overdose antidotes.

A hypertensive 70-years old female with history of heart failure with routinely consume spironolactone, diltiazem, and beta blocker admitted with bradycardia and shock after watery diarrhea and vomit 3 days before. The electrocardiogram showed junctional rhythm 40 beats per minutes. Laboratory findings Hyperkalemia (6.8 mEq/L) and acute kidney injury (urea 58.6 mg/dL, creatinine 3.13 mg/dL, eGFR 16.23) was presented. Refractory hyperkalemia occured, but by using pacemaker, providing adequate fluids, and the return of renal perfusion, hyperkalemia can be overcome.

BRASH syndrome usually triggered by hypotension in the elderly due to hypovolemia or an overdose of antihypertensive drugs. The natural compensation response for hypotension is to increase heart rate, but AV-nodal blockers blunt this response, which causes a decrease in renal perfusion. This ultimately results in hyperkalemia and accumulation of AV-nodal blockers which produce a synergistic effect causes bradycardia and decreased renal perfusion. Treatment involves supportive care including hemodynamic support with fluids and management of bradycardia, and also avoid trigger factor.