Bradycardia, Renal Failure, Atrioventricular Nodal Blockade, Shock, and Hyperkalemia (BRASH) Syndrome: A Frequently Overlooked and Underdiagnosed Condition.

Bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia (BRASH) syndrome is defined by the simultaneous presence of its five hallmark features. Despite its potentially severe clinical implications, it is frequently underdiagnosed due to symptom overlap with other conditions. Increased awareness and understanding of this syndrome are essential for prompt diagnosis and effective management, which are key to preventing serious morbidity. A 65-year-old male with a medical history of cirrhosis, portal hypertension, heart failure with reduced ejection fraction, chronic kidney disease, and ventricular bigeminy presented with dizziness and low blood pressure, which had started six to seven days prior. On initial examination, he was found to be bradycardic, with a heart rate in the 30s, and laboratory findings revealed hyperkalemia (6.6 mEq/L) and acute kidney injury (creatinine 2.9 mg/dL). The patient had been on a stable dose of metoprolol, an AV nodal blocking agent, which was recently reduced in the clinic due to worsening renal function. BRASH syndrome was suspected in the ED, prompting initiation of treatment with an epinephrine drip and insulin to address the hyperkalemia. Upon admission to the ICU, cardiac catheterization revealed nonobstructive coronary artery disease. The patient's condition improved over five days, with normalization of potassium levels, restoration of normal sinus rhythm, and resolution of kidney injury, ultimately leading to recovery. At discharge, metoprolol was discontinued, and close cardiology follow-up was arranged. Recognizing BRASH syndrome as a multifaceted clinical entity is critical. Early identification and a comprehensive approach to managing the interdependent components - bradycardia, renal failure, and hyperkalemia - are essential to halt the syndrome's progression and improve patient outcomes.