Bradycardia, Renal Failure, Atrioventricular-Nodal Blockade, Shock, and Hyperkalemia Syndrome: A Case Report

Bradycardia, renal failure, atrioventricular (AV) blockade, shock, and hyperkalemia (BRASH) syndrome is an uncommon and relatively new entity that results from synergy between AV nodal blockade and renal failure leading to a vicious cycle of hypotension, profound bradycardia, and hyperkalemia. Classically, this syndrome is seen in a patient taking AV nodal blocking agents and underlying renal insufficiency. We are presenting a case of a 76-year-old female with a medical history of essential hypertension and non-insulin-dependent type 2 diabetes mellitus presented to the emergency room with a chief complaint of dizziness and generalized weakness. The patient was taking metoprolol tartrate 200 mg twice a day, amlodipine 10 mg once daily, clonidine 0.1 mg twice daily, enalapril 20 mg twice daily, and Metformin 750 mg twice daily. On presentation, the patient had symptomatic bradycardia resistant to atropine with heart rate in 30s and hypotension resistant to volume expansion. The laboratory results showed that the patient also had acute kidney injury and severe resistant hyperkalemia. The whole presentation raised the suspicion of BRASH syndrome. The patient was started on peripheral dopamine infusion for bradycardia and symptomatic hypotension. Nephrology was consulted, and the patient was started on urgent dialysis for resistant hyperkalemia. The patient was admitted to the cardiovascular intensive care unit, and all antihypertensive medication, including beta-blockers, were stopped. The patient clinically improved on the next day, the dopamine infusion was stopped, and the patient remained vitally stable. The patient was eventually discharged home with cardiology and nephrology follow-up. The purpose of this case report is to help with the early diagnosis of this under-recognized and new clinical condition and to discuss the pathophysiology and management.