Hemodynamics of BRASH syndrome observed in gerontology

Objective: BRASH syndrome is characterized by bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia. All these factors form a vicious cycle. However, the clinical profile of this unique syndrome in superaged society is unknown and hence the objective of this study. Methods: Cases of BRASH syndrome were recruited from patients hospitalized in our geriatric hospital within the last two years. Results: Two patients with this syndrome were prescribed with β-blockers and calcium channel blockers, and the triggers of this syndrome were gastric bleeding and urinary tract infection, respectively. Hypermagnesemia found in a case also underlies this syndrome, because magnesium is an intrinsic calcium channel blocker leading to AV nodal suppression. Discussion: Heart failure (HF) pandemic is coming in many countries. Guideline-recommended medications of HF have improved the prognosis of HF patients worldwide. However, such medications may induce either hyperkalemia, hypovolemia, or AV nodal inhibition leading to bradycardia. Dehydration and hemoconcentration also cause BRASH syndrome triggered by pandemic coronavirus disease 2019 (COVID-19). Hyperviscosity and hypercoagulability are reported, and erythrocyte filterability is impaired in COVID-19 patients. However, the exact hemorheological mechanisms of BRASH syndrome caused by COVID-19 are a matter of future research. Conclusion: Accurate diagnosis and appropriate management are required in patients with BRASH syndrome especially in the post COVID-19 era.