A Needle in a Haystack: Uncovering the Rare Combination of BRASH Syndrome, Case Report

Background The combination of bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia, known as BRASH syndrome, is a severely underdiagnosed condition with a reported mortality rate exceeding 5.7%. Recognizing its symptoms and causes as interconnected is essential, as they create a self-perpetuating cycle that can cause rapid deterioration without prompt intervention. This review covers the diagnosis and management of BRASH syndrome. Discussion/Case Our patient presented with ideal conditions for BRASH syndrome. He had undiagnosed sinus node dysfunction, which, combined with propranolol, Imdur, olmesartan, and recently increased amlodipine, triggered this syndrome. His antihypertensive regimen led to hypotension and acute kidney injury. As his kidneys failed to clear potassium, he developed hyperkalemia, which exacerbated his sinus node dysfunction, leading to severe symptomatic bradycardia. At this stage, the patient entered the characteristic cycle of BRASH syndrome, necessitating urgent intervention to prevent progression to shock and worsening hyperkalemia. Conclusion The combination of bradycardia, renal failure, AV nodal blocking agents, shock, and hyperkalemia can be lethal. Effective management requires an approach that addresses each component of this syndrome. This review underscores the importance of understanding the underlying triggers and pathophysiology, particularly in elderly patients with polypharmacy, as timely diagnosis and treatment significantly improve outcomes.