Khan Arshan, Lahmar Abdelilah, Ehtesham Moiz, Riasat Maria, Haseeb Muhammad
Internal Medicine, Ascension St. John Hospital, Detroit, USA.
Medicine, Faculty of Medicine and Pharmacy/Mohammed VI University Hospital, Oujda, MAR.
Cureus. 2022 Mar 25;14(3):e23486. doi: 10.7759/cureus.23486. eCollection 2022 Mar.
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.
缓慢性心律失常、肾衰竭、房室传导阻滞、休克和高钾血症（BRASH）综合征是一种罕见且相对较新的病症，它由房室结阻滞与肾衰竭之间的协同作用导致，进而引发低血压、严重心动过缓和高钾血症的恶性循环。典型情况下，该综合征见于服用房室结阻滞剂且伴有潜在肾功能不全的患者。我们报告一例76岁女性病例，该患者有原发性高血压和非胰岛素依赖型2型糖尿病病史，因头晕和全身无力为主诉就诊于急诊室。患者正在服用酒石酸美托洛尔200毫克，每日两次；氨氯地平10毫克，每日一次；可乐定0.1毫克，每日两次；依那普利20毫克，每日两次；二甲双胍750毫克，每日两次。就诊时，患者出现对阿托品耐药的症状性心动过缓，心率在30次/分左右，且对扩容治疗耐药的低血压。实验室检查结果显示患者还存在急性肾损伤和严重的难治性高钾血症。整个临床表现引发了对BRASH综合征的怀疑。患者开始接受外周多巴胺输注以治疗心动过缓和症状性低血压。咨询了肾病科，患者因难治性高钾血症开始接受紧急透析。患者被收入心血管重症监护病房，所有抗高血压药物，包括β受体阻滞剂，均被停用。患者在第二天临床症状改善，多巴胺输注停止，生命体征保持稳定。患者最终出院，由心脏病科和肾病科进行随访。本病例报告的目的是帮助早期诊断这种未被充分认识的新临床病症，并讨论其病理生理学和治疗方法。
