A Combination of Beta-Blockade and Calcium Channel Blockade Leading to Bradycardia, Renal Failure, Atrioventricular Blockade, Shock, and Hyperkalemia (BRASH) Syndrome: A Case Report

The BRASH syndrome is a recently recognized syndrome and the acronym stands for bradycardia, renal failure, atrioventricular (AV) blockade, shock, and hyperkalemia. We discuss a case of a 56-year-old female with a history of heart failure who presented in a critical state following recent adjustments to her carvedilol dosage while she was simultaneously on verapamil. This combination of AV nodal-blocking agents induced bradycardia in the patient, leading to shock and renal hypoperfusion complicated by hyperkalemia that required the use of a temporary transvenous pacemaker before she made a full recovery. The case report highlights the fact that this combination of medications alone may have had a synergistic effect that led to BRASH in our patient.