PO-05-238 BRASH SYNDROME: A RARE BUT REVERSIBLE CAUSE OF SINUS NODE DYSFUNCTION

Abstract

Brash syndrome consists of a constellation of symptoms including bradycardia, renal failure, AV nodal blocking medicarions, shock, and hyperkalemia. The pathophysiology comprises of synergistic effects of AV nodal blockers and renal dysfunction with electrolyte abnormalities escalating the effect of AV nodal blockade. As a result, this syndrome is more prevalent in patients with cardiac and renal related comorbidities including end stage renal disease and hypertension requiring AV nodal blockers for treatment. Patients presenting with brash syndrome can develop a wide range of clinical symptoms from asymptomatic bradycardia to cardiogenic shock. Brash syndrome is critical to recognize because if left untreated it can lead to life threatening complications multiorgan failure and death. We present a case of a 57-year-old female with past medical history of CAD s/p PCI, HFpEF with grade 2 diastolic dysfunction, hypertension, hyperlipidemia, diabetes, asthma, ESRD on hemodialysis with frequent admissions for recurrent bradycardic episodes associated with missed hemodialysis sessions who presented to the emergency department with complaints of weakness, nausea, vomiting and multiple syncopal episodes. The patient was found to be hypotensive and bradycardic on admission for which dopamine drip was initialed. The EKG revealed sinus arrest with a junctional escape rythm at 33 beats/minute. The lab work was significant for hyperkalemia for which urgent hemodialysis was performed. The patient's home medication included carvedilol which was discontinued. Several attempts to wean off dopamine during the first 24 hrs were unsuccessful due to perisistent hypotension and bradycardia. The patient was monitored in the ICU for 48hrs on the dopamine drip after which it was successfly weaned off and patient mantained normal sinus rhythm. n/a n/a Brash syndrome is a rare cause of transient, reversible sinus node dysfucntion and bradycardia. Management involves early diagnosis, hemodyncamic support, discontinuation of AV nodal blocking agents. It is important to monitor the patient for 24-48 hrs after potassium correction as the sinus node recovery may not be immediate. Permamnent pacemaker placement should be avoided as this condition is reversible.