Clinical characteristics of BRASH syndrome: Systematic scoping review



      Bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia (BRASH) syndrome is a recently-established entity precipitated by medication-induced AV nodal blockade. Despite its serious consequences, including death, clinical presentations, risk factors, and outcomes of the syndrome have not been well defined. We aim to summarize the existing evidence of BRASH syndrome.


      According to the PRISMA Extension for Scoping Reviews, we performed a search on MEDLINE and EMBASE for articles with keywords including“BRASH syndrome” and “bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia,” from the inception of these databases to March 4, 2022.


      34 articles, including one observational study, 15 conference abstracts, and 18 case reports and case series, were included. While most patients were on beta blockers (83.3%) or calcium channel blockers (45.2%), other medications such as amiodarone were identified as precipitating agents. Atropine or glucagon were ineffective in reversing patients’ symptoms, and 59.5% required inotropes or chronotropes. 7.1% expired due to BRASH syndrome.


      This systematic review summarizes the clinical characteristics of BRASH syndrome. Further studies to identify risks associated with the onset of BRASH syndrome and awareness of the critical syndrome are warranted.


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        • Farkas J.D.
        • Long B.
        • Koyfman A.
        • Menson K.
        BRASH Syndrome: bradycardia, Renal Failure, AV Blockade, Shock, and Hyperkalemia.
        J Emerg Med. 2020; 59: 216-223
        • Kawabata M.
        • Yokoyama Y.
        • Sasaki T.
        • Tao S.
        • Ihara K.
        • Shirai Y.
        • et al.
        Severe iatrogenic bradycardia related to the combined use of beta-blocking agents and sodium channel blockers.
        Clin Pharmacol. 2015; 7: 29-36
        • Grautoff S.
        • Holtz L.
        Hyperkalemia and BRASH syndrome in emergency medicine: clinical significance and association with ECG findings.
        Notfall und Rettungsmedizin. 2020; 23: 172-179
        • Schnaubelt S.
        • Roeggla M.
        • Spiel A.O.
        • Schukro C.
        • Domanovits H.
        The BRASH syndrome: an interaction of bradycardia, renal failure, AV block, shock and hyperkalemia.
        Intern Emerg Med. 2021; 16: 509-511
        • Bailuni Neto J.J.
        • Siqueira B.L.
        • Machado F.C.
        • Boros G.A.B.
        • Akamine M.A.V.
        • Cordeiro de Paula L.J.
        • et al.
        BRASH syndrome: a case report.
        Am J Case Rep. 2022; 23e934600
        • Srivastava S.
        • Kemnic T.
        • Hildebrandt K.R.
        BRASH syndrome.
        BMJ Case Rep. 2020; 13
        • Cheung J.C.H.
        • Law K.L.
        • Lam K.N.
        Too slow and too high.
        Hong Kong J Emerg Med. 2020;
        • Ravioli S.
        • Woitok B.K.
        • Lindner G.
        BRASH syndrome - Fact or fiction? A first analysis of the prevalence and relevance of a newly described syndrome.
        Eur J Emerg Med. 2021; : 153-155
        • Dumond S.
        • Sirajee S.
        • Bonk M.P.
        • Bradycardia Bowden F.
        renal failure, atrioventricular nodal blockade, shock and hyperkalemia (BRASH) syndrome in the setting of amiodarone use.
        Am J Respir Crit Care Med. 2021; 203
        • Patel H.
        • Fischer W
        Do not be brash: octreotide-induced syndrome of bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia.
        Chest. 2021; 160: A649
        • McGowan J.
        • Straus S.
        • Moher D.
        • Langlois E.V.
        • O'Brien K.K.
        • Horsley T.
        • et al.
        Reporting scoping reviews-PRISMA ScR extension.
        J Clin Epidemiol. 2020; 123: 177-179
        • Tricco A.C.
        • Lillie E.
        • Zarin W.
        • O’Brien K.K.
        • Colquhoun H.
        • Levac D.
        • et al.
        PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation.
        Ann Intern Med. 2018; 169: 467-473
        • Diribe N.
        • Le J.
        Trimethoprim/sulfamethoxazole-induced bradycardia, renal failure, AV-node blockers, shock and hyperkalemia syndrome.
        Clin Pract Cases Emerg Med. 2019; 3: 282-285
        • Ghumman G.M.
        • Kumar A.
        BRASH syndrome leading to cardiac arrest and diffuse anoxic brain injury: an underdiagnosed entity.
        Cureus. 2021; 13: e18628
        • Gouveia R.
        • Veiga H.
        • Costa A.A.
        • Pereira J.
        • Bradycardia Lourenço P.
        Renal failure, atrioventricular nodal blockade, shock, and hyperkalemia syndrome due to amlodipine: a case report of an underdiagnosed medical condition.
        Cureus. 2022; 14: e21144
        • Grigorov M.V.
        • Belur A.D.
        • Otero D.
        • Chaudhary S.
        • Grigorov E.
        • Ghafghazi S.
        The BRASH syndrome, a synergistic arrhythmia phenomenon.
        Proc (Bayl Univ Med Cent). 2020; 33: 668-670
        • Prabhu V.
        • Hsu E.
        • Lestin S.
        • Soltanianzadeh Y.
        • Bradycardia Hadi S.
        Renal failure, atrioventricular nodal blockade, shock, and hyperkalemia (BRASH) syndrome as a presentation of coronavirus disease.
        Cureus. 2019; 12 (2020): e7816
        • Sattar Y.
        • Bareeqa S.B.
        • Rauf H.
        • Ullah W.
        • Bradycardia Alraies MC.
        Renal failure, atrioventricular-nodal blocker, shock, and hyperkalemia syndrome diagnosis and literature review.
        Cureus. 2020; 12: e6985
        • Arif A.W.
        • Khan M.S.
        • Masri A.
        • Mba B.
        • Talha Ayub M.
        • Doukky R
        BRASH syndrome with hyperkalemia: an under-recognized clinical condition.
        Methodist Debakey Cardiovasc J. 2020; 16: 241-244
        • Aytha S.K.
        A case of BRASH syndrome, refractory acidosis necessitating multimodal approach to treat it.
        J Clin Diagn Res. 2021; 15: KD01-KKD3
        • Flores S.
        Anaphylaxis induced bradycardia, renal failure, AV-nodal blockade, shock, and hyperkalemia: a-BRASH in the emergency department.
        Am J Emerg Med. 2020; 38 (e1-.e3): 1987
        • Park J.I.
        • Jung M.S.
        • Lee H.
        • Kim H.
        • Oh J.
        Implication of AV node blockers in patients with end-stage renal disease undergoing head and neck surgery; BRASH syndrome: a case report.
        Braz J Anesthesiol. 2022; 72: 152-155
        • Savage P.
        • McEneaney D.
        BRASH syndrome: an under recognised cause of complete heart block in the elderly.
        Ulster Med J. 2020; 89: 123-124
        • Vishnu V.K.
        • Jamshed N.
        • VT Amrithanand
        • Thandar S.
        BRASH Syndrome: a Case Report.
        J Emerg Med. 2021; 60: 818-822
        • Wong C.K.
        • Jaafar M.J.
        Bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia: an important syndrome to recognize.
        Turk J Emerg Med. 2021; 21: 86-89
        • Zaidi S.A.A.
        • Shaikh D.
        • Saad M.
        • Vittorio T.J.
        Ranolazine Induced Bradycardia, Renal Failure, and Hyperkalemia: a BRASH Syndrome Variant.
        Case Rep Med. 2019; : 2019
        • Abid A.
        BRASH syndrome with complete heart block: a unique presentation of a novel clinical syndrome.
        Crit Care Med. 2021; 49 (1 SUPPL): 647
        • Alipour O.
        A BRASH case of liver injury.
        Am J Gastroenterol. 2021; 116: S1150
        • Golchin A.
        • Zhou M.
        • Khan A.H.
        Bradycardia, renal failure, av-nodal blockers, shock, and hyperkalemia (BRASH)-a new clinical syndrome.
        Am J Respir Crit Care Med. 2018; 197
        • Gonuguntla K.
        • Patil S.
        • Manek G.
        • Tandon V.
        • Kaur A
        BRASH syndrome: lost in plain sight.
        Chest. 2019; 156: A2228
        • Gronbeck K.
        • Langenfeld J.
        A case of BRASH (bradycardia, renal failure, av blockade, shock, hyperkalemia) syndrome.
        Crit Care Med. 2022; 50 (1 SUPPL): 759
        • Gulati U.
        • Nanduri A.
        • Juneja P.
        • Kumar A.
        An atypical case of COVID-19 and renal amyloidosis presenting with BRASH syndrome.
        Crit Care Med. 2021; 49 (1 SUPPL): 146
        • Liou J.
        • Kaneria A.
        • Weiss S
        BRASH syndrome: an entity between hyperkalemia and atrioventricular nodal blockade toxicity.
        Chest. 2020; 158: A937
        • Moradi N.
        • Antwiler K
        Are beta blockers as safe as we think for elderly? BRASH syndrome a commonly missed diagnosis.
        Chest. 2021; 160: A119
        • Rai B.
        • Gorder K.
        • Berry K.
        • Smith T
        Transvenous pacing improves hemodynamics in the syndrome of bradycardia, renal failure, atrioventricular nodal blockade, shock and hyperkalemia.
        J Am Coll Cardiol. 2021; 77: 2072
        • Rosal N.
        • Thelmo F.
        • Tzarnas S.
        • Madara J.
        BRASH syndrome: a downward spiral.
        Chest. 2021; 160: A735
        • Sarkar S.
        • Rapista N.
        • Rout A.
        • Chaudhary R
        Bradycardia renal failure AV nodal blockade shock hyperkalemia (BRASH) syndrome: a deadly combination of AV nodal blockers in the setting of hypertensive crisis.
        Chest. 2020; 157: A132
        • Siu M.K.M.
        • Naveed M.
        • Owrangi M.E.
        • Rasul A.
        Fixing the kidneys to fix the heart: BRASH syndrome, a case report.
        J Am Soc Nephrol. 2020; 31: 468
        • Sohal S.
        • Ramachandran A
        Syndrome of bradycardia, renal failure, atrioventricular nodal blockers, shock, and hyperkalemia (BRASH syndrome): a new clinical entity?.
        Chest. 2019; 156: A74
        • Nagamine T.
        BRASH syndrome associated with angiotensin receptor blocker and SGLT2 inhibitor.
        Can J Emerg Med. 2022; 24: 99-100
        • Erdmann E.
        Safety and tolerability of beta-blockers: prejudices and reality.
        Eur Heart J Suppl. 2009; 11: A21-AA5
        • Lin Y.C.
        • Lin J.W.
        • Wu M.S.
        • Chen K.C.
        • Peng C.C.
        • Kang Y.N.
        Effects of calcium channel blockers comparing to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in patients with hypertension and chronic kidney disease stage 3 to 5 and dialysis: a systematic review and meta-analysis.
        PLoS One. 2017; 12e0188975
        • Lee J.H.
        • Ryu H.M.
        • Bae M.H.
        • Kwon Y.S.
        • Lee J.H.
        • Park Y.
        • et al.
        Prognosis and natural history of drug-related bradycardia.
        Korean Circ J. 2009; 39: 367-371
        • Hery E.
        • Jourdain P.
        • Funck F.
        • Bellorini M.
        • Loiret J.
        • Thebault B.
        • et al.
        [Prediction of intolerance to beta blocker therapy in chronic heart failure patients using BNP].
        Ann Cardiol Angeiol (Paris). 2004; 53: 298-304