Brash syndrome


  • Combination of:
  • Vicious cycle: in setting of medications, hyperkalemia, renal failure
  • Often initiated by an episode of hypovolemia, hypoperfusion, or uptitration of antihypertensives or K sparing diuretics
  • Renal failure causes hyperkalemia (+/- accumulation of AV node blockers), hyperkalemia synergizes with AV node blockers to cause bradycardia and hypoperfusion, hypoperfusion worsens renal failure [1]

Clinical Features

Differential Diagnosis

Symptomatic bradycardia


  • May have only mild hyperkalemia, with bradycardia out of proportion to degree of hyperK
  • EKG: may mot have typical findings of hyperkalemia


  • Hyperkalemia treatment (e.g. IV insulin/dextrose, albuterol, IV calcium, kaliuresis or dialysis)
  • IVF resuscitation for hypovolemia
  • Catecholamines (e.g. epinepherine) for persistent bradycardia/shock
  • Consider isoproterenol
  • Targeted treatments for beta-blocker or CCB overdose not helpful
  • May not respond well to atropine or transcutaneous pacing
  • Aggressive early diuresis


  • Admit, typically to ICU setting

See Also

External Links


  1. Hegazi MO, et al. Junctional bradycardia with verapamil in renal failure--care required even with mild hyperkalemia. J Clin PHarm Ther. 2012;37(6):726-8.