BRASH syndrome in a patient with coexisting anxiety disorder and long- term benzodiazepine use: A case report

Abstract

Background: BRASH syndrome represents a constellation of symptoms characterized by bradycardia, renal impairment, AV block, shock, and hyperkalemia. This vicious cycle leads to rapid clinical worsening and requires optimal management. This case illustrates the importance of rapid decision-making and management to navigate the critical phase of BRASH syndrome.

Case Summary: A 73-year-old woman with a pre-existing anxiety disorder presented with sudden generalized fatigue and several episodes of dyspnea. The initial electrocardiogram (ECG) revealed bradycardia (30 beats/min) with episodes of sinus arrest, RBBB, and PVC bigeminy. Laboratory tests indicated hyperkalemia, hyponatremia, elevated blood urea nitrogen, and elevated creatinine levels. Long-term alprazolam and recent bisoprolol use were documented in this patient. Dopamine was administered for inotropic and vasopressor support. Calcium gluconate was given, and a temporary pacemaker was considered. After three days of hospitalization, the patient's condition improved, with an ECG showing a heart rate of 66 beats per minute and improved renal function following the correction of hyperkalemia.

Discussion: We recommend considering BRASH syndrome in patients presenting with bradycardia and hyperkalemia with recent AV nodal blocking agent use. In our case, bisoprolol was the most likely precipitating factor. The patient's long-term alprazolam use was also noted; while any potential modulatory role remains speculative, it may warrant further investigation. It is important to recognize this so that appropriate synergistic treatment for all contributing factors can be implemented, rather than focusing on a single component.